Charged with Manslaughter for a drug error.
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- čas přidán 31. 01. 2012
- Franck Guilloteau starts by describing the circumstances that lead to the death of a 16 year old pregnant woman who was in labour and being looked after by Julie Thao.
After an intense double shift, (16.75 hours) and less than 6 hours of sleep before starting a third shift, Julie was very fatigued. Although appropriately labelled, the infusion bags were identical in size, shape, and connectors. She did not try to use the bar code scanning device on the clear bags because of difficulties she had encountered during the prior 2 shifts with the same type of infusion bags. She inadvertently mixed up the antibiotic and epidural bags and delivered the epidural medication through the patient's intravenous route meant for the antibiotic. When it was discovered that the wrong medication was delivered through the wrong route resulting in the death of a young mother, Julie collapsed and was admitted to the hospital as a psychiatric patient.
In the weeks that followed, she was terminated from her post with no severance compensation and criminally charged by the state attorney general; when she returned to her hospital for pastoral care, she was instructed by an administrative director not to return to the property. During the darkest hours that followed, she felt entirely abandoned, facing the possibility of jail time, a large fine, and loss of her license.
Ultimately, because of the cost of continuing to trial, she plea-bargained to accept a conviction of 2 misdemeanours. Thus, she did not have to serve a jail sentence. The board of nursing also concluded their investigation and opted not to revoke Julie's license and to allow her to practice again within a year. However, her life will never be the same after having made a fatal human error that was predisposed by systems failures and human factors. Subsequently, she has been embraced by leaders of the patient safety community to help make her story a learning case that can prevent harm to patients, caregivers, and our hospitals.
For more information regarding human factors:
www.risky-business.com/
Any nurse who says she has not had some type of medication error either didn't catch it or is a new nurse. There are 92,000 deaths or serious injuries related to medical errors every year. We all need to use the technology available and just slow down and don't be afraid to say no...no I won't work the extra shift...no I can't take the extra patient...
Exactly, did not catch it, hasn't worked long, and I would add one more possibility...a liar. We must work to improve processes and appropriate care of the caregivers to include preshift assessments for rest.
Glad to hear her story. It sad how a hospitals turns their back on those who serve for decades. Unfortunately they do that and wonder why there's a revolving door or staff. Keep tour head up keep sharing your story!
It’s not her story to be telling
Thank you Julie for sharing your story. This is so important.
While professionals should be held accountable for their actions, the fact that medical institutions allow, or require, those in certain positions to work such long hours should also be culpable for their decisions.
I agree, this happens at my current job all the time.
Nurses are pressured to work extra hours. This situation was so sad. The hospitals do not have enough nurses & overload those they have.
Peppie Tan I feel like we really need more nurses. Sucks that the nursing programs are so competitive that only some make it
In our unit, anesthesia alone handles, prepares, and sets up ANY anesthetic agent.
Yes, to make the doctors more time, nurses were assigned another job.
Thank you Julie!
Thank you Julie.
Do not override the 5 Rs...it does need a scanner
IT was a systems failure, she has tortured herself and blamed herself enough. This way she can reach other nurses and medical staff and try to prevent it happening again.
BS the fault is hers, she is the one that did not use the bar code, she is the one that did not bother to read the chart to determine the correct medication, they are labeled you know. No she kill that woman and her baby. She is the one that used the wrong medication. As for all the great nursing she did before, how many good deeds does it take to cover up two murders? Ask the loved ones she left behind. She is no different than a tired driver that runs a stop sign and kills 2. both are negligent murder. Medical mistakes kill about 200,000 in the US every year. it is the culture of "the system is to blame" that allows this to continue. 2 10 year consecutive sentences would go a long way to correcting this murders problems.
So sad
Crazy! Loss of license should be sufficient.
I feel for you Julie, it is the system that fail indispensable nurses like you. Hang tight my dear!!
Diligence....not simply being careful....
Again make life easier for the anesthesia staff at the expense of safety oh and lets not forget the cheap computer systems but the nurse is in the wrong. I hope she sued them.
Julie, my heart goes out to you! I have read all the comments and I believe people that want to through stones at you must be perfect or have blinders on! There was an issue with the system! Just like you stated, the event was bound to happen because of the system. Too often when systems are put in place, they seem to be great in the beginning but as time goes on, the glitch in the system comes out. There are many systems, processes, even policies that are events waiting to happen. If a culture could be adopted to have not only the family but the healthcare worker that was involved in the event, be part of the team that addresses how to keep the event from happening again, it would not only be a preventative measure but also part of the healing process. Who better to help keep events from reoccurring than the people that were involved. Yes, the family's are affected, but the healthcare provider also suffers, a lot of times in silence with guilt, self doubt, and feelings of being worthless, when in fact, they were failed by the system that was meant to protect them and the patient.
Systems are in place to "help" and not to dictate healthcare practice. Healthcare professionals are well compensated to carry our their fiduciary duty to heal and not harm the patient. It is tragic that 100,000 patients die because of incompetence. Stop blindly follow whatever system is in place. You must supercede when the system is faulty. Be a human, not a humanoid.
What did she lose compared to the family? She’s doing tours and probably getting paid by telling someone else’s story about losing and “having a mental breakdown..” if y’all wanna hear the real story that actually matters . Lmk
This makes my tummy sick, us nurses put our life on the line and when a human error happens ours lives change forever 😭
You should be in jail.
It is sad to read some judgmental comments here. This is a very sad situation for both the innocent pt. that lost her life due to this tragic event and also the nurse who DIDN'T intend to cause her death. What do you want her to do commit suicide, she was already went that road and had to be on suicide watch. What should happen moving on is assess the whole situation that lead up to this event. I am a medsurge nurse of 3 years experience. Stories like this are wakeup call for me to be vigilant about my work. It doesn't matter of how many years of experience you may have, it only takes that one mistake to change your and your patient's life. Also, the hospitals and managers don't ask you if you had enough rest or sleep when they ask you to pick up extra shift. They just want that shift to be covered inspite of your condition. So, as a nurse you should make sure you are capable of taking care of people. On the story they sated that because they wanted the anesthesiologist not to stay on the floor they put the pt's safety at risk which is so absurd. So, when i hear this story I see the whole picture not just the nurse. Thank you for sharing your story so that other nurses can learn from this and give safe patient care.
What a sociopath. It wasn't a mistake that she committed. But "It" happened. Like she wasn't there or it was some out of body experience. And how her daily struggle is blah blah, blah. She is not in prison, and still has her nursing license but somehow goes on world tour seeking more sympathy. For what exactly? She said it wasn't her fault...
At first I was angry at Julie for this medication error killing the pregnant girl who just turned 16. But this wasn’t Julie’s fault. This could have happened to any nurse. It’s not your fault Julie!!! ❤❤❤❤
I don't care how tired you were, don't kill people.
Unlike people who kill people.
Your being funny and I think most of the nurses who waste time reading your insult will swat it like a fly. No one just gets tired and kills ppl. Your def not a nurse so you just sound ignorant and dont know what your talking about.
Are you a medic?
Nurses don’t intentionally kill people. How ignorant of you to say that. I feel sad for both parties.
Stop being soo o judgemental!