Using the GCU Library, locate and summarize an allied health malpractice or negligence case study. If possible, select a case within your chosen field of study. What went wrong? What workplace safety, risk management, and/or quality improvement steps were involved? What could have been done differently? If you were in charge of making sure this type of event never occurred again, what steps would you implement into the risk management plan?
You are required to use and cite a minimum of two references from the GCU Library to support your response.
Case Study: Julie Thao Medication Error (Allied Health – Nurse)
Summary of the Case (What Went Wrong):
Julie Thao, a nurse with over 25 years of experience at St. Mary’s Hospital in Madison, Wisconsin, accidentally administered an epidural anesthetic, bupivacaine, to a 16‑year‑old laboring patient (Jasmine Gant) instead of the intended antibiotic, penicillin. The medications were packaged similarly, and due to distractions and workload pressures, Thao failed to verify the correct drug before administration. Tragically, the patient died within hours as a result of the error. Studocubrightonpapers.com
Workplace Safety, Risk Management, and Quality Improvement Measures Involved:
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Medication administration protocols existed (e.g., double‑checking before administering), but they were not properly followed in this case.
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There was no systemic differentiation between medications with similar packaging to prevent mix‑ups. Studocubrightonpapers.com
What Could Have Been Done Differently:
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Implement a barcoding system requiring nurses to scan both the patient’s wristband and the medication to ensure correct matching.
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Redesign or distinguish medication packaging to avoid similar appearances that contribute to confusion.
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Enforce strict adherence to medication-check protocols (e.g., read-back, two-person check).
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Manage workloads to reduce fatigue and distractions. Studocubrightonpapers.com
Risk Management Plan: Preventing Recurrence (If You Were in Charge):
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Technology‑Based Verification: Install barcode-enabled medication administration systems and electronic alerts for mismatches.
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Packaging Safeguards: Collaborate with pharmacy and suppliers to redesign packaging that clearly differentiates look-alike medications.
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Staff Training & Competency Checks: Conduct recurrent training on safe medication administration and reinforce protocol adherence through simulations.
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Workload Monitoring: Use staffing algorithms to ensure adequate nurse-to-patient ratios, especially in high-stress units like labor and delivery.
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Just Culture and Reporting: Encourage non-punitive incident reporting of near-misses and errors to facilitate learning and system-wide improvements.
Secondary Supporting Source: Systemic Contributing Factors in Medication Errors (International Example)
To deeply ground your analysis with a systemic view, I also located a broader study from Sweden examining 585 nurse-related malpractice medication errors over 11 years. This adds depth by exploring both individual and system factors, which is vital for risk management planning.
Findings (What Went Wrong):
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Common individual factors: negligence, forgetfulness, lack of attentiveness (68%); not following protocols (25%); lack of knowledge (13%); practicing beyond professional scope (12%).
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Common system factors: role overload (36%); unclear communication or orders (30%); insufficient access to guidelines or unclear organizational routines (30%). PMC
Relevance to Your Case & Risk Management:
This study underscores that medication errors often arise from a combination of human factors (e.g., inattentiveness, fatigue) and systemic issues (e.g., unclear protocols, workload pressure)—exactly what was seen in the Thao case.
What Could Be Done Differently (Aligned with This Bigger Picture):
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Address role overload by ensuring manageable shifts and staffing levels.
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Improve communication protocols—standardized verbal or electronic handovers, clear orders.
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Provide ready access to guidelines, such as job aids at medication stations.
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Clarify scope of practice and ensure staff operate within their competencies.
Final Integrated Recommendations
By combining the Julie Thao case specifics with the system-level insights from the Swedish study, here’s a robust set of recommendations:
| Risk Factor | Mitigation Strategy |
|---|---|
| Similar Packaging | Redesign packaging and institute barcode verification. |
| Distraction/Fatigue | Monitor and optimize staffing; allow uninterrupted medication prep time. |
| Protocol Non‑Compliance | Regular training, competency checks, and enforcing read‑back/double‑check protocols. |
| Role Overload | Ensure appropriate staffing to reduce workload, fatigue. |
| Communication Gaps | Adopt clear, standardized handoff procedures and medication order formats. |
| Poor Organizational Routines | Make guidelines accessible and visible; use quick-reference job aids. |
References (Minimum Two from GCU‑Accessible/Sourced Material)
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Julie Thao medication error case study (nurse administered wrong medication due to packaging confusion and distraction) Studocubrightonpapers.com
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Swedish study on medication errors in nursing—individual and system contributory factors
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