Julie Thao born December 14, 1964 was a Registered nurse in the state of Wisconsin who worked as a labor and delivery nurse from 1993 through July 5, 2006 at St. Mary’s Hospital in Madison. She had worked almost 17hrs on July 4, 2006 and was extremely fatigued by the end of her shift that ended at midnight. She spent the night at the hospital to avoid her hour-long commute home. She began another scheduled 8hour shift at 7:00AM on July 5,2006 when she received her assignment of two patients at the birthing unit. One of her patients was Jasmine Gant who had just turned 16 years old with her first pregnancy. She was scheduled for induction of labor that morning because she was past due date of June 29, 2006. From the word go, Julie Thao failed to put the patient ID bracelet on Grant per facility protocol. Grant birth plan was to have a natural birth and manage her pain with pain pill or IV pain medication without an epidural. Grant was positive for beta streptococcus group B which required her to receive a prophylaxis order of IV penicillin during labor.
Julie Thao received orders from the doctor and proceeded to retrieve medications from pyxis. She took ordered medications and anticipated epidural would be ordered too thus removed epidural medications without an order and placed all the medications on the counter in anteroom to Grant’s room. IV penicillin was delivered as well from pharmacy and added to the other medications on the counter. When Julie Thao was ready to administer the IV penicillin, she inadvertently mixed up the antibiotic and epidural bag, failed to scan the barcodes and use the Bridge Medical, failed to read the label on the mini-bag containing epidural, failed to do the three checks, and failed to follow the five rights of medication administration. She mistakenly administered the epidural anesthetic (Bupivacaine) intravenously instead of IV penicillin.
Almost immediately upon receiving the epidural IV, Gant started having adverse reaction. She experienced convulsions, central nervous system complications, and cardiac arrest. A Code Blue was called, and advanced cardiopulmonary life support was performed without success. Grant died because of poisoning by intravenous anesthetic (Epidural/Bupivacaine). Her child was delivered by emergency Caesarean section at 12:20PM. According to the 2004 study by Rogers, Hwang, Scott, Aiken, & Dinges, it was found that working longer shifts, voluntary and mandatory overtime, and excessive workloads are all risk factors that dangerously contribute to nurse fatigue leading to several medication errors and sentinel events for errors increases. The effects of fatigue on nurses leads to problems such as: compromised problem-solving skills, decreased attention span, delayed reaction time, memory lapses, impaired communication, and inability to focus, which are all important for nurses to be aware of to provide quality and safe patient care.St. Mary hospital staffing pattern created a hazardous condition for patient safety whereby workers were encouraged to work longer shifts and awarded for extra shifts they picked up.
The Labor & Delivery (L&D) unit was short staffed with several nurses on temporary leave (Smeltzer, Baker, Byrne & Cohen, 2010). If Julie Thao had not worked second shift, they would have been staff-challenged. Julie Thao’s extreme fatigue had a tremendous effect on the actions leading to the medication error. The formal work condition in the L&D unit that Julie Thao worked focused on physician satisfaction more than patient safety. The nurses were expected to use a list to guide them and prepare the epidural medications with its paperwork before the anesthesiologist arrival to minimize the time he/she spend in the unit. Nurses did not directly communicate with the Anesthesiologist making it difficult to have the epidural ready upon their arrival. Despite having a series of safety measures in place to safeguard medication and avoid medication administration errors beyond the “five rights”, they were not enforced. Julie Thao was able to retrieve epidural medications from the pyxis without doctor’s order.
The computer system that was supposed to be used to scan the barcode on medication before it was given was relatively new in the L&D unit and it was not compatible with the design on the medication bags thus giving nurses a hard time. The new system’s constant problems created low rates on compliance on scanning IV bags, and nurses were bypassing the system, which included safety features to prevent such errors from happening. Nurses could hang the medications and document manually. This showed that training about the recent technology was insufficient to the L&D staff and especially for Julie Thao who was out for a week during the time the new system was introduced in the unit.The other contributing factor to this unintentional error was failure to read the label on the medication administered. The bag containing the epidural solution and the bag of the penicillin looked similar in size. They were both clear solutions. The two bags had orange label stickers, but the epidural bag had an additional bright pink warning label. There is also a design flaw in the interconnectivity making the IV tubing compatible with accessing the epidural bag port like it does with the IV solutions (Smeltzer, Baker, Byrne & Cohen, 2010).
Pharmaceutical companies need to do a better job to make their treatments less similar looking in bag style, labels, IV tubing, etc. In awake of the unintentional error, Julie Thao was charged with one count of neglect of a patient causing great bodily harm, a felony that can result in a significant fine and imprisonment. After plea bargaining, she was placed on 3 years criminal probation. She was also sanctioned by the Wisconsin Nursing Board. She received a suspension of her nursing license for 9 months as of July 6,2006. Upon the end of the suspension, she was placed on practice limitations for 2 years which included: she could not work more than 12 hours in any 24 consecutive hours or more than 60 hours in any 7 consecutive days; she must complete an approved educational program, which total 54 hours addressing the role of individuals and systems in preventing medication and health care errors; she must make 3 presentations to groups of nurses or nursing students for at least one hour each; and she must pay a $2500 fine within 120 days.
I believe that the judgment by the State Board of Nursing was justified because as Nurses, we are responsible for the care we give to our patients regardless the environment or condition we are in. Nurses have a legal and ethical duty to protect their patients from foreseeable harm and have a code of conduct to follow while they practice. Nurses are the backbone of the patient and are expected to use their nursing knowledge as well as physical and emotional skills to care for the patient. Sometimes nursing care can be stressful. Nurses are trained and need to frequently be reminded to be extra vigilant, careful, ask questions, take breaks and take care of themselves to become effective in maintaining patient safety which is critical. The choices they make can save or cost a life. Julie Thao had worked many hours before this happened and was understandably exhausted.
She picked all these hours voluntarily and wasn’t mandated and should have been able to make a nursing judgement that her mind and body couldn’t take another shift. According to a you tube video, Julie Thao is now working as a certified patient safety officer at the Institute of Health Care Improvement with the Texas Medical Institute of Technology (TMIT), a medical research organization. It produces multimedia stories to improve patient safety in hospitals and Thao speaks as a motivational speaker. Her story has been an inspiration and basis for nationally recognized safe practice addressing the care of the caregiver involved in adverse event. Her case is used to avoid and prevent future harm to both patient and caregiver. She teaches that tragic errors can have a profound effect on the caregiver who was responsible for the error as well as the patient and hospitals must recognize that the caregiver also needs support after such events.
BIBLIOGRAPHYC.
- (2012, February 01). Charged with Manslaughter for a drug error. Retrieved January 10, 2018, from https://www.youtube.com
- Rogers, A.E., Hwang, W., Scott, L.D., Aiken, L.H. and Dinges, D.F. (2004)
- The working hours of hospital staff nurses and patient safety. Health Affairs, 23, 202-212. http://dx.doi.org/10.1377/hlthaff.23.4.202Smeltzer J, Baker C, Byrne FB, Cohen MR [2010].
- Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Jt Comm J Qual Patient Saf 36:152-163.