1. Mee, Cheryl L. RN, BC, CMSRN, MSN

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Have you been following the story of the Wisconsin nurse who accidentally administered the wrong drug to a patient, who died as a result? Now the nurse is facing a felony charge of criminal neglect. If convicted, she could face a $25,000 fine and up to 6 years in jail.1

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Julie Thao, RN, intended to administer I.V. penicillin to treat a strep infection in a teenage girl in labor. Instead, she picked up a bag of the epidural anesthetic bupivacaine and infused it through the I.V. line. The patient had a seizure within minutes and died later that day. The baby, a boy, was delivered successfully by cesarean section.


I grieve for the dead girl and her family, but pressing criminal charges against this nurse is wrong. It's also contrary to best practices for handling medication errors. Research has shown that punishing individuals for errors discourages reporting, which is essential to root out unsafe practices and prevent them from endangering more patients.2 Fear of retribution also takes a toll on nurse recruitment and retention.


Unfortunately, hundreds of errors occur in health care every day because imperfect people are working under imperfect conditions. As the last line of defense, nurses often get the blame when an error reaches a patient. But further investigation is likely to uncover myriad problems that contributed to the error.


That's what we learned 10 years ago, when three Denver nurses were charged with negligent homicide after giving a neonate a fatal overdose of I.M. penicillin G benzathine intravenously. When experts at the Institute for Safe Medication Practices analyzed circumstances and trial evidence in that case, they identified over 50 systemic flaws that let the error reach the patient.3 (Only one nurse went to trial, and a jury acquitted her.)


The "five rights" of medication safety are as important as ever, but they can't compensate for systemic problems or the many human factors that contribute to errors.4 Better drug labeling and equipment designed to prevent wrong-route administration are just two changes that would help prevent dangerous errors. So would strict policies that prevent nurses from working more than 12 hours in a 24-hour period,2 as Thao reportedly did just before the fatal incident.


Nurses go to work motivated to help their patients-certainly not wanting to harm them. If a nurse is negligent, discipline by the employer and the state nursing board may be appropriate. But pressing criminal charges is dead wrong.


Cheryl L. Mee, RN, BC, CMSRN, MSN


Editor-in-Chief, Nursing2007,




1. State of Wisconsin v. Julie Thao, 2006 CF2512, Wisconsin Cir., Dane County, November 2, 2006. [Context Link]


2. Page A (ed). Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, D.C., The National Academies Press, 2004. [Context Link]


3. Smetzer JL. Lesson from Colorado: Beyond blaming individuals. Nursing98. 28(5):48-51, May 1998. [Context Link]


4. The five rights cannot stand alone. ISMP Medication Safety Alert!! Nurse Advise-ERR. 2(11):1, November 2004. [Context Link]