Medical Ethics Advisor
February 2, 2007
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, 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.
According to the investigator's report, Thao:
- improperly removed the epidural bag from a locked storage system without authorization or permission;
- did not scan the bar code on the epidural bag, which would have told her it was the wrong drug;
- 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.
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 statewide 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.
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.
Quality News Today is an ASQ member benefit offering quality related news
from around the world every business day.