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Sorry Works! Blog

Making Disclosure A Reality For Healthcare Organizations 

Hospital Apologizes for Baby Mix-Up, Nurse Gets Fired

Below are links for a recent story where newborns got mixed up, one baby was given to the wrong mother who breastfed, and when the error was discovered the involved parents were justifiably horrified.  Oak Bend Hospital outside Houston, TX apologized to the involved parents and families and did testing to rule out diseases. Then, according to the several media report below, a nurse was fired after the investigation was completed. Hmmm...

Maybe the parents demanded the nurse be fired!  It happens all the time in acute and long-term care organizations: "I want that nurse or doctor fired!"  Maybe the nurse had it coming?  Maybe she/he had a spotty track record?  Or maybe she/he was a stellar employee and great nurse, the kind of person you would want caring for you or your family member, but she/he was involved in a mistake or what might be more accurately classified as a "system error?"

Who knows?

We will probably never know all the details of why this nurse got fired....but here's what I do know: The next time an adverse event happens at Oak Bend Hospital the staff will be that much more reluctant to speak up and self-report.  Moreover, health care professionals in other organizations who have heard (or will hear) about this story will remember it when deciding to self-report an adverse event.

No good deed goes unpunished, goes the old saying.

Folks, we need to be more thoughtful about these situations. 

For example, I'm really curious to know what is happening with this fired nurse right now.  Is anyone checking up on the nurse?  Making sure she/he is OK?  Is she/he receiving support, counseling, etc?  I wrote all about the second victim of medical errors in 2013 here:

Another thought: Instead of firing the nurse, was she/he given the chance to be part of the disclosure process, meet with and apologize to the parents, and be part of the system fixes?  Could you imagine what this would do for not only disclosure at this hospital (and others), but also what it would do for morale at this hospital?  All the sudden Oak Bend would become an employer of choice for nurses.  The message would be clear: Oak Bend Hospital supports their staff when something goes wrong.   Wow!  When a patient or family demands that a nurse or doctor be fired (or disciplined in some other fashion), you are hearing anger.  Work with that anger.  Acknowledge it.  Be empathetic.  And try to lower the temperature by being pro-active with both the consumer and caregiver(s), and maybe down the road you can get the consumer and caregiver(s) reconnected.

Then there is this thought: Some hospitals have unionized nurses (don't know if Oak Bend is in this camp, or not)...but if your hospital has unionized nurses have you talked with the union about disclosure?  Seriously. Because, in an attempt to protect their members from being fired, unions can get in the way of disclosure, healing, learning from mistakes, etc.  Wrote about this issue here:

Also, I'll never forget the sage advice given to me from the CEO of a long-term care organization: "I would never fire a good person who made an honest mistake.  As a result of the mistake, I now have a real investment in that person.  He/she will do everything they can to make sure the mistake never happens again.  You don't fire a person like support them!"

But what if the nurse truly had it coming?  He/she was an accident waiting to happen?  Well, as the Ethel Waters quote says, "God Doesn't Make Junk."   Maybe this nurse had missed his/her calling, but she still has a heartbeat given by God and we need to move this person along to something better suited to their talents.  Instead, however, to report to the media that the nurse got "fired" is crude, will destroy staff morale, and impede disclosure and patient safety efforts at this hospital and others.  Here are a couple media reports on this story:


Seriously, folks, we need to be more thoughtful, caring, and compassionate when dealing with the second victims of medical errors.

Hey, next Thursday, January 23rd at 1pm ET/12 CT is our next free preview webinar of our new on-line disclosure training courses developed with The Sullivan Group.  See how we are teaching disclosure to front-line staff.  To reserve your spot simply e-mail

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