St. Mary's Nurse Is Charged: Medication Error
HCA501
Project : Case showing problems created by nurse staff.
Professor: Dr.Muna Saloman
Project by: Varun Reddy Chintakunta
SID: 000228836
CASE "St. Mary's Nurse is Charged; Medication Error Led to Teen's Death" describes the criminal complaint
A Wisconsin nurse who was arrested on a felony charge stemming from an unintentional medical error that led to the death of a patient last summer will serve three years of probation after pleading no contest to reduced charges, but medical and nursing societies are concerned about the effect the case might have in future medical error situations.
Julie Thao was a nurse at St. Mary's Hospital in Madison, WI, in the summer of 2006 when 16-year-old Jasmine Gant was admitted to give birth. Through a series of actions, shortcuts, …show more content…
and omissions, all of which Thao accepted responsibility for at her sentencing in December, she mistakenly gave Gant an epidural anesthetic (Buvipacaine) intravenously. Gant was supposed to receive an IV antibiotic for a strep infection. Within minutes of receiving the epidural IV, Gant suffered seizures and died. Her child, a boy, was delivered by emergency Caesarean section and survived.
EXPLANATION BY THE NURSE:
Thao reportedly told investigators that she got the epidural bag to show it to Gant, placing it on a counter--where another nurse placed the penicillin. Apparently Thao later picked up the wrong bag and injected it. Gant soon began seizing
INVESTIGATOR’S REPORT
A) Improperly removed the epidural bag from a locked storage system without authorization or permission;
B) Did not scan the bar code on the epidural bag, which would have told her it was the wrong drug;
C) Ignored a bright pink warning label on the bag that stated the drug was for epidural administration only; and disregarded St. Mary's "5 rights" rule for drug administration — right patient, right route, right medication, right dose, and right time.
News reports quoted Thao saying, "This was my mistake, everything was my fault" at the time of her plea. She will serve three years on probation, her license has been suspended for nine months, and should she return to nursing (she was fired from St. Mary's), she will face close scrutiny of her hours and work performance.
COUNTER-ACT
Despite the action by the state nursing board in chastising Thao and suspending her license, medical and nursing associations have been almost unanimous in protesting the felony criminal charges in a case of a mistake.
"It is imperative that all health care professionals do everything possible to ensure that medical errors do not happen. Patient safety is critical," according to Ruth Heitz, JD, general counsel to the Wisconsin Medical Society. "But to use the criminal justice system in this unprecedented manner to prosecute acts of unintentional medical errors is likely to have a chilling effect on the practice of medicine.
"Humans make mistakes. That is an unfortunate reality."
St. Mary's Hospital faced regulatory action and possible loss of its Medicare contract in the wake of Gant's death, but the violations were retracted when St. Mary's initiated staff re-education programs to address the issues that led to the error.
State and federal regulatory and licensing agencies' investigations "will improve the safety and quality of care" at Wisconsin hospitals and "will have a profound impact on the hospital, hospital staff" and Thao, according to Dana Richardson, RN, a spokeswoman for the Wisconsin Hospital Association.
"We are concerned, however, that unlike the other agencies involved in this case, actions by the [Department of Justice charging Thao] will actually have a negative impact state wide on the accessibility to and quality of care provided in Wisconsin," says Richardson. "Health professionals enter health care knowing that a mistake could cost them their license, livelihood, and financial stability. What is incomprehensible is entering a career where a single error could lead to imprisonment."
The state nursing board has suggested that Thao was overworked on the day of the error. She had worked a 16-hour shift that ended at midnight the previous day, and slept at the hospital so she could be back on duty at 7 a.m. Gant's death occurred shortly after noon.
FINAL DECISION:
As part of the sanction by the state board, if Thao returns to work as a nurse, she cannot work more than 12 hours a day, and she is limited in the areas of hospital nursing she can practice.
Wisconsin officials believe they've done the right thing by charging Madison nurse Julie Thao with a felony for making a fatal medication error at St. Mary's Hospital . "The circumstances of the case go well beyond a simple mistake," contends Mike Bauer of the Department of Justice.
Indeed they do. Which is why pressing charges against a veteran nurse is going to make hospitals less safe.
Thao worked on a labor and delivery unit until she was fired four months ago. For 15 years, she had, by all accounts, been an exemplary RN. Yet she accidentally delivered a powerful painkiller, rather than penicillin, to a young woman who was giving birth. The anesthetic stopped Jasmine Gant's heart, causing her death (although hospital staff were able to save her baby).
CONTRARY TO THE THEORY OF INDIVIDUAL BLAME:
This terrible tragedy confirms what a 1999 report by the Institute of Medicine found -- that medical errors are usually the result of system failures.
In this particular case, from what we know now, the system failures included excessive RN overtime work, which led to dangerous fatigue; poorly designed medication packaging and checking; improperly functioning drug bar coding; and insufficient training with computer systems.
Numerous studies have shown that long hours and sleep deprivation adversely affect the performance of RNs and physicians. Researchers have warned hospitals that error rates increase after staff members have been on the job for more than eight to 10 hours at a time -- and when they fail to get adequate rest between shifts. Yet health care employers around the country, including St. Mary's, impose no limits on RN overtime.
Many hospitals actively encourage nurses to work additional hours beyond their scheduled shift. Because the basic shift for many RNs is now 12 hours instead of eight, "overtime" can mean a workday that's 14 or 15 hours long.
The day before this tragic error, Julie Thao had worked back-to-back shifts, for a total of 16 hours. It was midnight, and she was due back at the hospital at 7 a.m. So, rather than drive home and back, she spent what was left of the night in a hospital bed.
The medication error that cost Gant her life should have been impossible to make.
If the epidural anesthesia needed to reduce the pain of labor and delivery had been packaged in a bag whose cap did not fit onto the main IV, no one could have put it directly into the bloodstream instead of the epidural space around the spine. If, as in some hospitals, two nurses check and double-check IV bags before they are hooked up to the main pump, this reduces the likelihood of error.
Instead of such safeguards, hospitals, like St. Mary's, are putting increasing faith in what are known as bar code computerized medication administration (BCMA) systems, which nurses use to scan bar codes on drugs and on patients' ID wristbands. This supposedly prevents nurses from giving the wrong patient the wrong drug, or administering the wrong dose, at the wrong time, through the wrong route.
Researchers like Ross Koppel at the University of Pennsylvania Medical School have documented the many errors these so-called error-proof devices actually create. Although promising, they do not work 100 percent of the time, says Michael Cohen at the Institute of Safe Medication Practices. Nor do they work with all
medications.
The bar code systems, just like the bar codes in supermarkets, in fact, have so many glitches that nurses must frequently bypass them.
In the case of the newly installed medication bar code system in St. Mary's, Thao insists that the system was having problems reading clear IV bags, just like the ones used for the patient. Also, she says, the system had been having problems that week, and nurses were specifically instructed to give the medications when needed and document them manually. Plus, Thao was not fully trained in the system's use. Unfortunately, none of these system errors will be addressed if the state continues to blame an individual for system failures and tries to criminalize what was clearly a mistake.
The state's hospital, nursing and medical associations and nursing unions have protested these charges because they recognize that patients will only be safe when error is openly reported, discussed, and corrected in a nonpunitive environment.
Nurses, doctors, pharmacists, lab techs and other health care workers will never admit to errors and help to illuminate their causes if they fear that they will lose their jobs, go to jail or face serious financial consequences.
Although discussion of nursing errors is often painful, it helps to show the public that the profession is a serious one, in which skilled professionals must make life-and-death decisions in caring for patients.
Project : Case showing problems created by nurse staff.
Professor: Dr.Muna Saloman
Project by: Varun Reddy Chintakunta
SID: 000228836
CASE "St. Mary's Nurse is Charged; Medication Error Led to Teen's Death" describes the criminal complaint
A Wisconsin nurse who was arrested on a felony charge stemming from an unintentional medical error that led to the death of a patient last summer will serve three years of probation after pleading no contest to reduced charges, but medical and nursing societies are concerned about the effect the case might have in future medical error situations.
Julie Thao was a nurse at St. Mary's Hospital in Madison, WI, in the summer of 2006 when 16-year-old Jasmine Gant was admitted to give birth. Through a series of actions, shortcuts, …show more content…
and omissions, all of which Thao accepted responsibility for at her sentencing in December, she mistakenly gave Gant an epidural anesthetic (Buvipacaine) intravenously. Gant was supposed to receive an IV antibiotic for a strep infection. Within minutes of receiving the epidural IV, Gant suffered seizures and died. Her child, a boy, was delivered by emergency Caesarean section and survived.
EXPLANATION BY THE NURSE:
Thao reportedly told investigators that she got the epidural bag to show it to Gant, placing it on a counter--where another nurse placed the penicillin. Apparently Thao later picked up the wrong bag and injected it. Gant soon began seizing
INVESTIGATOR’S REPORT
A) Improperly removed the epidural bag from a locked storage system without authorization or permission;
B) Did not scan the bar code on the epidural bag, which would have told her it was the wrong drug;
C) Ignored a bright pink warning label on the bag that stated the drug was for epidural administration only; and disregarded St. Mary's "5 rights" rule for drug administration — right patient, right route, right medication, right dose, and right time.
News reports quoted Thao saying, "This was my mistake, everything was my fault" at the time of her plea. She will serve three years on probation, her license has been suspended for nine months, and should she return to nursing (she was fired from St. Mary's), she will face close scrutiny of her hours and work performance.
COUNTER-ACT
Despite the action by the state nursing board in chastising Thao and suspending her license, medical and nursing associations have been almost unanimous in protesting the felony criminal charges in a case of a mistake.
"It is imperative that all health care professionals do everything possible to ensure that medical errors do not happen. Patient safety is critical," according to Ruth Heitz, JD, general counsel to the Wisconsin Medical Society. "But to use the criminal justice system in this unprecedented manner to prosecute acts of unintentional medical errors is likely to have a chilling effect on the practice of medicine.
"Humans make mistakes. That is an unfortunate reality."
St. Mary's Hospital faced regulatory action and possible loss of its Medicare contract in the wake of Gant's death, but the violations were retracted when St. Mary's initiated staff re-education programs to address the issues that led to the error.
State and federal regulatory and licensing agencies' investigations "will improve the safety and quality of care" at Wisconsin hospitals and "will have a profound impact on the hospital, hospital staff" and Thao, according to Dana Richardson, RN, a spokeswoman for the Wisconsin Hospital Association.
"We are concerned, however, that unlike the other agencies involved in this case, actions by the [Department of Justice charging Thao] will actually have a negative impact state wide on the accessibility to and quality of care provided in Wisconsin," says Richardson. "Health professionals enter health care knowing that a mistake could cost them their license, livelihood, and financial stability. What is incomprehensible is entering a career where a single error could lead to imprisonment."
The state nursing board has suggested that Thao was overworked on the day of the error. She had worked a 16-hour shift that ended at midnight the previous day, and slept at the hospital so she could be back on duty at 7 a.m. Gant's death occurred shortly after noon.
FINAL DECISION:
As part of the sanction by the state board, if Thao returns to work as a nurse, she cannot work more than 12 hours a day, and she is limited in the areas of hospital nursing she can practice.
Wisconsin officials believe they've done the right thing by charging Madison nurse Julie Thao with a felony for making a fatal medication error at St. Mary's Hospital . "The circumstances of the case go well beyond a simple mistake," contends Mike Bauer of the Department of Justice.
Indeed they do. Which is why pressing charges against a veteran nurse is going to make hospitals less safe.
Thao worked on a labor and delivery unit until she was fired four months ago. For 15 years, she had, by all accounts, been an exemplary RN. Yet she accidentally delivered a powerful painkiller, rather than penicillin, to a young woman who was giving birth. The anesthetic stopped Jasmine Gant's heart, causing her death (although hospital staff were able to save her baby).
CONTRARY TO THE THEORY OF INDIVIDUAL BLAME:
This terrible tragedy confirms what a 1999 report by the Institute of Medicine found -- that medical errors are usually the result of system failures.
In this particular case, from what we know now, the system failures included excessive RN overtime work, which led to dangerous fatigue; poorly designed medication packaging and checking; improperly functioning drug bar coding; and insufficient training with computer systems.
Numerous studies have shown that long hours and sleep deprivation adversely affect the performance of RNs and physicians. Researchers have warned hospitals that error rates increase after staff members have been on the job for more than eight to 10 hours at a time -- and when they fail to get adequate rest between shifts. Yet health care employers around the country, including St. Mary's, impose no limits on RN overtime.
Many hospitals actively encourage nurses to work additional hours beyond their scheduled shift. Because the basic shift for many RNs is now 12 hours instead of eight, "overtime" can mean a workday that's 14 or 15 hours long.
The day before this tragic error, Julie Thao had worked back-to-back shifts, for a total of 16 hours. It was midnight, and she was due back at the hospital at 7 a.m. So, rather than drive home and back, she spent what was left of the night in a hospital bed.
The medication error that cost Gant her life should have been impossible to make.
If the epidural anesthesia needed to reduce the pain of labor and delivery had been packaged in a bag whose cap did not fit onto the main IV, no one could have put it directly into the bloodstream instead of the epidural space around the spine. If, as in some hospitals, two nurses check and double-check IV bags before they are hooked up to the main pump, this reduces the likelihood of error.
Instead of such safeguards, hospitals, like St. Mary's, are putting increasing faith in what are known as bar code computerized medication administration (BCMA) systems, which nurses use to scan bar codes on drugs and on patients' ID wristbands. This supposedly prevents nurses from giving the wrong patient the wrong drug, or administering the wrong dose, at the wrong time, through the wrong route.
Researchers like Ross Koppel at the University of Pennsylvania Medical School have documented the many errors these so-called error-proof devices actually create. Although promising, they do not work 100 percent of the time, says Michael Cohen at the Institute of Safe Medication Practices. Nor do they work with all
medications.
The bar code systems, just like the bar codes in supermarkets, in fact, have so many glitches that nurses must frequently bypass them.
In the case of the newly installed medication bar code system in St. Mary's, Thao insists that the system was having problems reading clear IV bags, just like the ones used for the patient. Also, she says, the system had been having problems that week, and nurses were specifically instructed to give the medications when needed and document them manually. Plus, Thao was not fully trained in the system's use. Unfortunately, none of these system errors will be addressed if the state continues to blame an individual for system failures and tries to criminalize what was clearly a mistake.
The state's hospital, nursing and medical associations and nursing unions have protested these charges because they recognize that patients will only be safe when error is openly reported, discussed, and corrected in a nonpunitive environment.
Nurses, doctors, pharmacists, lab techs and other health care workers will never admit to errors and help to illuminate their causes if they fear that they will lose their jobs, go to jail or face serious financial consequences.
Although discussion of nursing errors is often painful, it helps to show the public that the profession is a serious one, in which skilled professionals must make life-and-death decisions in caring for patients.