Kimberly Hiatt was a pediatric critical care nurse who accidentally gave an infant a fatal overdose of calcium chloride last year.

By accounts, it was a calculation error. A human mistake.

After the incident, the hospital fired her.

This past April, she took her own life.

Although it cannot be concluded that the tragedy was directly responsible for her suicide, the incident clearly took a tremendous toll on her:

“She absolutely adored her job” at Children’s, where she had worked for about 27 years … “It broke her heart when she was dismissed … She cried for two solid weeks. Not just that she lost her job, but that she lost a child.”

Should the hospital have fired her?

Former hospital CEO Paul Levy argues that placing blame on a single person detracts from the hospital’s overall responsibility of improving system processes to prevent future instances:

Punishment of those involved in this case also would have diverted attention from the failures of senior management in doing its job … It also would have diminished the likelihood of widespread interdisciplinary participation in redesigning the work flow in our ORs. By making clear that the error was, in great measure, a result of systemic problems, all felt a responsibility to be engaged in helping to design the solution.

Indeed, when a surgeon was involved in a wrong-site surgery under Mr. Levy’s tenure at Boston’s Beth Israel Deaconess Hospital, he was not punished, as “a ‘just culture’ approach to the issue would suggest that further punishment would not be helpful to our overall goal of encouraging reports of errors and near misses.”

I agree.

Kimberly Hiatt made a mathematical error that led to the tragic death of an infant patient. Firing her simply absolved the hospital from their share of the blame. Instead, she should have been involved with the subsequent improvement process to prevent future errors.

Now, with her suicide, the tragedy has only been compounded, with no guarantee that it won’t happen again.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on Facebook, Twitter, and LinkedIn.