Julie Thao's Medication Attack Case Study

There were specific situations that led to the cause of Julie Thao's actions of medication error and the death of Jasmine. The situation could have completely been avoided had Julie followed the code of ethics and avoided shorts to provide proper care for the patient. The state claimed that Thao's mistake was caused by actions, omissions and unapproved shortcuts, however, there were other factors that played a role in her carelessness as well. While failure to comply with procedure has been a factor in the medication administration error, other factors contributed as well. For example, failure to properly use the information system, or to ignore alerts or warnings have also resulted in preventable errors (Nelson, Evan, & Gardener, 2005). At the time of the event, a bar coding system for all medication had been in effect for a duration of two weeks, however, Thao had been gone one of those crucial weeks. Because of her absence, she did not receive the adequate training, instead, she received a sped

Another major factor of Thao's medication error was fatigue. That had been picking up extra shifts, including the one in which she worked on the fourth of July. Her lack of proper rest and not giving her mind time to receive those eight hours caused the confusion between the two IV containing the two kinds of medication. Despite the fact that Thao had been a nurse for several years prior to the event, Thao did not follow the proper protocol to ensure that patient's safety. She gave her un-prescribed medication which resulted in Jasmines death. As a result, all these factors played a major role in the tragic death of her patient. If Jasmine took the time to professionally handle the situation correctly by taking care of her well-being by getting the proper sleep and paid closer attention like she should have the outcome of the situation could have turned out drastically