For 16 years Julie Thao had been a good obstetrics nurse, one highly regarded by her peers at St. Mary's Hospital in Madison, Wisconsin. She volunteered to work an extra shift on the July 4 holiday last year, after working an eight-hour day shift. Scheduled for a 7 am shift on July 5, she slept at the hospital at the end of the two shifts.
During the second half of that July 5 shift, Thao made a deadly error. She gave Jasmine Gant, a 16-year-old scheduled for induction of labor, iv bupivacaine (Marcaine, Sensorcaine), an anesthetic intended for epidural administration that had not been ordered, instead of the iv penicillin that had been prescribed to treat a streptococcal infection. Gant suffered a cardiac arrest and couldn't be resuscitated. Delivered by cesarean section, her infant Gregory lived.
Thao overlooked several steps intended to prevent such errors: Gant failed to apply the patient's ID wristband, use the bar-coding system installed on the unit three weeks earlier, and check the "five rights" of medication administration. Why? Perhaps it's because she had volunteered to work about 20 hours in a 28-hour period. Research has shown that working more than 12 hours in a 24-hour period is associated with fatigue and an elevated risk of errors.
Thao was initially charged with a felony, "criminal neglect of a patient causing great bodily harm," and then pled no contest to two misdemeanors. The Wisconsin Board of Nursing suspended her license for nine months, and she lost her job. Rightfully, the Wisconsin Nurses Association, the Institute for Safe Medication Practices (ISMP), the Wisconsin Hospital Association, and others opposed the criminalization of Thao's errors. As the ISMP noted, "criminal prosecution sends the false message that clinical perfection is an attainable goal, and that 'good' healthcare practitioners never make mistakes." (See In the News, page 20.) And the Joint Commission recently added the elimination of caregiver fatigue to a draft of its National Patient Safety Goals of 2008, citing its relationship to patient harm.
This case can serve as a powerful reminder to nurses who think they're doing the right thing by volunteering to work overtime or who refuse to fight for adequate staffing and against mandatory overtime. If you make a mistake, you may jeopardize your license, lose your job, be charged with and convicted of a crime, and as Thao reportedly acknowledged in court, be devastated by the results of an error that harms or kills a patient: "The anguish and remorse are a life sentence that I will serve for all time."
I recently met nurses at two Las Vegas facilities. They've been in contract negotiations for almost a year, but the hospitals are refusing to include safe staffing standards and eliminate mandatory overtime-the primary issues of concern to the nurses. In December the nurses threatened to strike, then withdrew the threat at the request of Nevada's governor, only to find themselves locked out of the hospitals for a week. They became the target of searches and other actions that their union, the Service Employees International Union, calls "intimidation," including the firing of Joan Wells and Christine Scofield, who had led the nurses' fight in the two hospitals. (At the end of January, the nurses and the hospital were working with a mediator.)
The December 6, 2006, issue of the Las Vegas Sun reported that Ann Savin, a nurse and system director of quality for Valley Health System (which owns one of the hospitals), told reporter Marshall Allen: "Sometimes we make more errors when we have more nurses on. They're distracted. They're talking among themselves" and denied that there was a link between nurse-patient ratios and outcomes. Either Savin isn't up on current research, or she has sold her soul for a job.
But is she any different from nurses and hospital administrators who refuse to speak out about unsafe care? All of us-administrators, educators, leaders of nursing organizations, and clinicians-must demand a safer health care system. That's what "good" nurses do. I believe that the public is on the side of the Las Vegas nurses, who don't want their patients to go the way of Jasmine Gant. And as nurses rally around Julie Thao and others treated like criminals when they make mistakes, let's not forget that Jasmine Gant died.