Since when is it a crime to be human?
Last week, a nurse from Wisconsin was charged with criminal “neglect of a patient causing great bodily harm” in the medication error-related death of a 16-year-old woman during labor.1 The nurse accidentally administered a bag of epidural analgesia by the intravenous route instead of the intended penicillin. For a copy of the complaint, click here.
Like other healthcare professionals around the county, ISMP staff were deeply saddened by the tragic loss of life in this case, and our prayers continue for the patient’s family. ISMP has also been supportive of the nurse involved since the error happened, as she works through the agony of having made a fatal error, facing potential action against her nursing license, and coping with the loss of her job of 15 years.
Now, as she faces the threat of 6 years in jail and a $25,000 fine, some may be hasty in their judgment of this case, without knowing all the facts. It is important to keep in mind that there is usually much more to a medication error than what is presented in the media or a criminal complaint. For example, while the criminal complaint alleges that the nurse failed to follow the “five rights2” and did not use an available bedside bar-coding system, some of the most safety-minded hospitals across the nation with bar-coding systems have yet to achieve a 100% scanning rate for patients and drug containers.
This incident is similar to a 1998 case involving three nurses in Denver who were indicted for criminally negligent homicide and faced a possible 5 year jail term for their role in the death of a newborn who received IV penicillin G benzathine.3,4 At first glance, it appeared to many that disciplinary measures might be warranted in that case. But when working pro bono for one nurse’s attorney, ISMP found more than 50 deficiencies in the medication use system that contributed to the error. Had even one of them been addressed before the incident, the error would not have happened or would not have reached the infant. Fortunately, in the Denver case, the nurse who stood trial was rightfully acquitted of the charges by a jury of laymen that deliberated for less than an hour.
While there is considerable pressure from the public and the legal system to blame and punish individuals who make fatal errors, filing criminal charges against a healthcare provider who is involved in a medication error is unquestionably egregious and may only serve to drive the reporting of errors underground. The belief that a medication error could lead to felony charges, steep fines, and a jail sentence can also have a chilling effect on the recruitment and retention of healthcare providers--particularly nurses, who are already in short supply.
ISMP supports the stance that the Wisconsin Hospital Association and Wisconsin Nurses Association have taken in opposing criminal prosecution of healthcare professionals for unintentional errors, and joins the many professional colleagues and friends who have been publicly supportive of Julie, the nurse involved in the Wisconsin case (See news release). Former patients have come forward in tribute to the competent and compassionate care they have received from Julie, and concerned friends and colleagues have started a fund to help support her defense. (Checks can be made payable to “Friends of Julie T” and sent to the Park Bank, P.O. Box 8969, Madison, WI 53708-8969.) If you would like to send a personal message to Julie, please send your correspondence to Julie@ismp.org or via our mailing address (ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044), and it will be forwarded.
If possible, ISMP will bring any details we learn about this error to healthcare providers across the nation so that all can learn from this tragedy. Until then, please reserve judgment on this case and recognize that medication errors could happen to any nurse.
1) Elbow S. St. Mary's nurse is charged with neglect: medication error led to teen's death. The Capital Times. Madison, WI: November 2, 2006. Accessed at: www.madison.com/tct/mad/topstories/index.php?ntid=105800&ntpid=1.
2) Institute for Safe Medication Practices. The five rights cannot stand alone. Nurse Advise-ERR. 2004; 2:1.
3) Smetzer JL, Cohen MR. Lesson from Denver medication error/criminal negligence case: look beyond blaming individuals. Hosp Pharm 1998; 33:640-56.
4) Smetzer JL, Cohen MR. Lesson from Denver. Institute of Medicine. Preventing Medication Errors. Aspden P et al. eds. National Academy Press: Washington, DC; 2006.