Aveneu Park, Starling, Australia

“Julie patients room and placed the penicillin

“Julie Thao was convicted on July 5, 2006 for Neglect of a Patient Causing
Great Bodily Harm, a Class H Felony, in violation of Wisconsin State” She has
been a nurse on OB for over 13 years, never had a mistake and seemed to be
attentive to her patients. One bad mistake cost her, her nursing license. Julie Thao (Circuit Court of Wisconsin
November 2, 2006)

“Julie worked at Saint Mary’s Medical Center when her 16 year old patient came
in past her due date, which she was scheduled for an induction on the birthing
unit. Julie did her normal routine of grabbing medications that might be used
for the delivery of her child and lactated ringers as the Doctor ordered. She
grabbed the epidural just in case the patient decided to go with this route. The
patient needed to be started on penicillin for a positive beta streptococcus
culture. Pharmacy brought down the penicillin to the patients room and placed
the penicillin on the counter. Julie grabbed the epidural medication which was
right next to the penicillin. Julie also did not check patient identifier to
make sure she had the right patient, the right dose, the right medication, the
right route, and the right rate/time. Julie did not use the patient’s wrist band
to scan the medication into the computer. She states she was going to manually
enter the medication after she started the “penicillin”. Julie hung the
epidural medication and started the infusion. Julie did not see the big pink
letters on the epidural that states, “caution epidural for epidural
administration only”. There was no rate of how fast to infuse the penicillin,
so she sped up the rate of the infusion from 180 ml/hr to 250 ml/hr. The
patient had a severe reaction almost instantly after the infusion started. The
patient started to have a stiff back, began seizing, gasping for air, and was
clenching her jaw. Julie seen this reaction and immediately removed the
piggyback from the main line. The healthcare team started to code the patient
and was successfully able to deliver her baby caesarean. The patient died after
delivery of the baby. Julie
Thao (Circuit Court of Wisconsin November 2, 2006)

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With this big tragedy, Julie had many ways she could have prevented this event
from happening. As Julie knew, the patient had a planned vaginal birth, and the
patient stated she did not want to have an epidural. Julie took out the
epidural medication without the consent of the Doctor. If Julie would have
followed the Doctor and patients plan, this whole event would have never happened.
The patient did not have a patient wrist band on to identify who she was. The
ward clerk stuck the wrist band on the chart for the nurse to apply when she
goes into assess the patient. Julie failed to do so. Julie also could have
avoided this event by scanning the medication and the patient as their hospital
policy stated to do. Julie had training on how to scan the patient and medication
to the patients chart. Although, Julie’s supervisor told her not to scan the
medication into the system as they were still working on the upgrade. With this
knowledge, Julie should have doubled checked to make sure she was giving the
right medication. Julie stated she was going to put in the medication into the
patients chart after she administered the medication. By doing so, Julie did
not follow the hospitals policy of 5 rights of medication, right patient, right
drug, right route, right dose, and right time. This was another key role in preventing
the death of the patient. There was bright label on the epidural IV bag,
stating “caution epidural, for epidural administration only”. Where the
penicillin bag had the Patient’s name and the name of medication. Julie should
have taken her time and made sure she was hanging the right medication. Julie Thao (Circuit Court of Wisconsin
November 2, 2006)

            With everything that happened to
Julie, she was able to keep her license under a few circumstances, she was
suspended for 9 months, can only work 12 hour shifts and no more than 60 hours
in a 7 day period. Julie needs to have a supervisor monitor her work
performance and complete 54 hours of education which addresses the roles of
individuals in the healthcare system and preventing medication errors. Once
Julie completes her requirements she will do 3 presentations to a group of
nurses or nursing students in regards to the roles of the healthcare team and
medication prevention. “Julie also had to pay money to the Department of
regulation and Licensing, if she fails to do so, her licenses will be suspended
without further notice or hearing.” Julie Thao (Circuit Court of Wisconsin November 2, 2006)

            With everything that happened with
Julie, I believe she got off easy. Julie ended up killing one person, and the
other one involved has major physical problems. The boy that was delivered has
health conditions that he should have never had to deal with. Julie should have
lost her nursing license for a longer period and attended more classes to prove
she was ready and more adequate to come back to work. With the knowledge she
had for a nurse of 13 years, she should have known better. She should have
communicated that she had too big of a workload to handle on her own on top of
having very little sleep. With this, it might have been possible that this
tragic event could have been stopped. Julie Thao (Circuit Court of Wisconsin
November 2, 2006)

            One good thing that came out of this
event is that Julie is now working on publishing medical journals to talk about
her story and hopefully prevent mistakes like hers for the future healthcare
workers. She works for Texas Medical Institute preparing brochures for
hospitals. Julie also works with families that have lost their loved ones due
to a medical mistake and working with the healthcare workers to prevent errors.

            Julie’s error has impacted nursing
and the healthcare field in many ways, the hospitals have many policies on
medication and the 5 rights, checking with a second nurse for high alert
medications, safe staffing, orientation, certifications if needed, and
department education. These are just few of the many policies the hospitals
incorporate to keep the patient as safe as possible during their stay.


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