A nurse's deadly medication error at St. Mary's Hospital nearly four years ago wasn't only her fault, suggests a new report identifying systemic problems at the hospital that enabled the mistake.
Pressure to prepare drugs early, acceptance of long working hours and sporadic use of patient wristbands and bar-code scanners contributed to Julie Thao's delivery of a spinal drug into the arm of 16-year-old Jasmine Gant during childbirth, according to the report being released today.
The report, in the Joint Commission Journal on Quality and Patient Safety, doesn't blame St. Mary's; it was written in part by two administrators at the hospital. But the report offers the first detailed look at problems - some present at many hospitals - that helped pave the way for Thao's erroneous delivery of epidural pain medication in July 2006. Gant was supposed to receive an antibiotic in her arm.
"We wanted to learn everything possible from this event ... and share what we learned in the interest of helping others avoid similar tragedies," said Dr. Frank Byrne, St. Mary's president.
The report helps remove some of the blame from Thao, said Dr. Charles Denham, chairman of the Texas Medical Institute of Technology, which gave her a fellowship to study patient safety. Her research led her to co-author a journal article this month with actor Dennis Quaid, whose children received an overdose of a blood thinner.
With the report about St. Mary's, "she really is vindicated," Denham said.
Thao declined to be interviewed.
Preparing drugs early
The mistake received national attention when Thao was charged with a felony. After she pleaded no contest to two misdemeanors, the state suspended her nursing license for nine months and put her on probation for two years. St. Mary's fired her, she and Denham have said, and the federal government banned her from working at hospitals or clinics for five years.
Gant's son, delivered by emergency cesarean section, survived and received a $1.9 million settlement from St. Mary's.
The hospital invited the Pennsylvania-based Institute for Safe Medical Practices to do a "root cause analysis" a year after the incident, and the report summarizes those findings. Researchers from the institute wrote the report with Byrne and Chris Baker, director of quality and safety systems at the hospital.
The report says pressure from anesthesiologists led nurses to prepare epidurals early, and Thao's retrieval of the drug without a formal order allowed a mix-up with the antibiotic. St. Mary's now requires orders to be signed by a doctor before nurses can get epidurals.
Halfway through the second of two eight-hour shifts the day before the mistake, Thao asked to go home because she was tired. However, St. Mary's refused because staffing would have been inadequate, the report says. Thao, who slept at the hospital before returning to work the next day, volunteered for the second shift and could have turned it down, Baker said in an interview.
St. Mary's now requires nurses who work 16 hours in a row to take 12 hours off before returning to work, a policy that would have prevented Thao from working the morning of the mistake.
Thao's failure to put a wristband on Gant and use a bar-code scanner to match medications to the wristband wasn't unusual, the report says. Nurses on her unit had a "tacit tolerance" of not applying wristbands and used the scanner only half the time, it says.
Baker said wristbands are required now, and the scanners - new in 2006 - are used 98 percent of the time in the unit today. She said the scanners are a backup to a more important step: nurses looking to see that they're giving the right drug.
In editorials accompanying the report, Denham and Dr. Lucian Leape, a patient safety expert from Harvard University, said St. Mary's should apologize to Thao and offer her restitution.
"She was scapegoated," Leape wrote. "To appease the family and the public. To deflect attention from the hospital's failures. And it worked. And it is deplorable."
Byrne said he and others at St. Mary's tried to prevent criminal charges from being filed against Thao, accompanied her to court hearings and asked the federal government to reverse her five-year employment ban.
"We did provide significant support to her," he said.
REPORT'S KEY POINTS
Systemic problems at St. Mary's Hospital helped cause a nurse's mistake that killed a 16-year-old patient in 2006, a report says. Those problems include:
EARLY EPIDURALS: Pressure to prepare epidural pain drugs in advance helped cause similar-looking epidural and antibiotic bags to be in the room.
OVERLOOKED LABELS: A pink warning label on the epidural bag was ignored, possibly because both bags also had orange labels; in addition, antibiotics weren't considered risky.
WRISTBANDS/SCANNERS: Sporadic use of patient wristbands and bar-code scanners to match drugs to the wristbands contributed to the nurse's failure to use them.
St. Mary's officials say the hospital now requires doctor-signed orders for epidurals; places warning labels on tubes, not just bags; and has greatly increased the use of wristbands and scanners.