Assignment Task:
The November 2 Capital Times piece reports that former St. Mary's Hospital nurse Thao has been charged with "neglect of a patient causing great bodily harm." Thao, who has lost her job at St. Mary's, faces up to six years in prison for the felony charge. The basic claim is that Thao mistakenly gave the 16-year-old Gant an epidural anesthetic intravenously, thinking the drug was penicillin prescribed for a strep infection Gant had. Gant reportedly died within the hour, though her son Gregory was delivered "successfully by Caesarian section." The piece focuses on Thao's alleged "failu[ure] to follow nearly every safeguard" the hospital had for preventing such errors. She allegedly failed to use the "Bridge System" of medication scanning, and failed to read the drug's "hot pink" warning label or follow the "five rights" of medication administration. Thao reportedly told investigators that she got the epidural bag to show it to Gant, placing it on a counter--where another nurse placed the penicillin. Apparently Thao later picked up the wrong bag and injected it. Gant soon began seizing. The piece reports that Thao's supervisor said the failure to scan the medication even after administering it "completely defeated the purpose of the system." The piece also notes that "[e]ven after injecting the drug, instead of scanning the label [Thao] started rewinding a video tape, the complaint states." The piece does say that Thao told an investigator that she had used the wrong bag in the excitement after Gant had become agitated, though "other accounts differed." The piece quotes Thao as saying: "I allow priority for compassion to override the need for detail." The piece does at least note that Thao has no past disciplinary actions against her.
1. How will the nurse reflect in action? (state what the nurse would observe with the patient that would indicate correct and safe practice has been followed, basically, how would the patient look if everything had been effective and safe)
2. What factors play into the error that is created in the system? How can the hospital and nursing unit interpret the problems and respond to them?