1. In 2006 Nurse Julie Thao was charged with felony criminal negligence in the death of a 16-year-old laboring mother when she mistakenly hung a bag of epidural medication instead of intravenous penicillin. Although the baby was successfully delivered via cesarean section, the client died following aggressive resuscitation attempts as a result of circulatory collapse. Nurse Thao was fired from her job of 16 years. Her felony charge was amended to two misdemeanor counts, and her state’s Board of Nursing suspended her license, imposed practice limitations upon return, mandated completion of an education program, and imposed a $2,500 fine. Beyond these sanctions, she stated at her sentencing hearing, “The anguish and remorse are a life sentence that will serve for all time.”

View the Chasing Zero Documentary on YouTube^[1]

Discuss factors that contributed to Nurse Julie Thao’s medication error. What reflections on your own nursing practice can be made after viewing this video clip? What actions might have been taken to avoid this error? Do you believe other members of the health care team were culpable in their actions?