When an error becomes a crime

Nurses should pay attention to a recent 2006 court case out of Wisconsin. In State of Wisconsin v. Julie Thao, Ms. Thao a nurse with 13 years of experience and an exceptional nursing practice history was charged with one count of neglect of a patient causing great bodily harm (which is a felony that can result in a significant fine and imprisonment). After plea bargaining, Ms. Thao was placed on 3 years criminal probation. Ms. Thao was also sanctioned by the Wisconsin Nursing Board. She received a suspension of her nursing license for 9 months, then she was placed on 2 years of restrictions (she could not work more than 12 hours per 24 hours or more than 60 hours per 7 days; she has to obtain 54 hours of CEUs in one year; she has to give 3 presentations to the nursing community and she has to pay a $2500 fine).

So what did Ms. Thao do that resulted in such actions? In July 2006, Ms. Thao worked 2 consecutive 8 hour shifts and then worked another 8 hour shift the next day on L&D unit. Midway through that shift, she pulled an epidural medication mini-bag (bupivacine & fentanyl) in anticipation of an epidural order for her 16 year old patient who was in labor. The mini bag was labeled with a bright pink label. She sat the mini-bag down at the bedside. She was supposed to hang a PCN piggyback, but instead she grabbed the epidural and administered it IV. The patient died (the baby was born by C-section).

Unfortunately, this is not the first time a health care provider has been charged with a crime as a result of their negligence. There have been other providers charged criminally such as a nurse for inserting a Foley catheter without an order (trying to obtain a urine specimen, the nurse botched the insertion resulting in the patient requiring a supra pubic catheter) or the provider who transported a patient in a wheelchair without putting the foot rests down causing the patient to pitch forward and suffer injuries from a fall. This is a disturbing trend that state nursing associations are trying to discourage.

Nurses need to be aware of ALL of the possible ramifications from nursing errors and take appropriate defensive action when an error occurs.