Can we live a "Just Culture?"

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On July 5, 2006 obstetrical nurse Julie Thao gave Jasmine Gant, a 16-year-old scheduled for induction of labor, IV bupivacaine (Marcaine), an anesthetic intended for epidural administration instead of the IV penicillin that had been prescribed to treat a streptococcal infection. The patient suffered a cardiac arrest and couldn't be resuscitated. An infant son was delivered by cesarean section.

This is a clear case of an adverse event that in health care is classified as a sentinel event, a medical error leading to death of a patient. Who is to blame? Who is responsible?

For 16 years Julie Thao had been a good obstetrics nurse, one highly regarded by her peers at St. Mary's Hospital in Madison, Wisconsin. Over the July 4 holiday she volunteered to work an extra shift, after working an eight-hour day shift. She was scheduled for a 7 am shift on July 5; she slept at the hospital at the end of the two shifts. The error occurred during the second half of that July 5 shift.


Nurse Thao allegedly failed to follow the “five rights” of medication administration (right patient, right medication, right dose, right time, and right route). She failed to use the patient's ID wristband bar-coding system installed on the unit three weeks earlier. The medications looked alike and were brought to the patient room before orders were given. She was obviously fatigued from working 20 of the prior 28 hours. Was she distracted, rushed?
Health care providers generally come to work to do a good job not to harm patients. They are, for the most part, dedicated individuals who see their work as a calling to improve the lot of mankind. What do we do when they make a horrible mistake?

St. Mary’s Hospital fired Julie Thao. The Wisconsin state board of nursing suspended her license and the state brought criminal charges. St. Mary’s Hospital settled a $1.9 million malpractice suit with the patient’s family. Nurse Thao was despondent. "I felt my soul banging on the inside of my chest to be set free," she said. "It could not bear to be inside this body, this person who had done this."

Several years ago David Marx, an engineer developed what is called Just Culture. Given the premise that most adverse events are a result of a system failure, errors are rarely caused solely by the actions of an individual. Individual responsibility for an error arises from intentional or reckless behavior or actions performed under the influence of drugs or alcohol.
Just culture may be difficult to implement. A young, healthy patient is dead. An orphaned infant, a grieving family and an outraged press and community exert tremendous pressure. How does the hospital respond? They fire the nurse.

An organization that adopts a Just Culture as one of its cornerstone principles should have a different response. First, the reason to use a Just Culture is have an organization where patient safety issues and concerns can be brought up in an open and safe atmosphere. An organization that uses individual blame will find that there is a scarcity of voluntary reporting, no learning and a poor safety record. Second, the initialization of a Just Culture starts with the board of directors and senior leadership. A standardized approach that investigates all incidents using an algorithm is needed.
The UK National Health Service has an on-line program that allows for a step by step evaluation of an adverse event.

The first point on the decision tree is whether the action was intended. If so, were the consequences intended? If not, did substance abuse play a role? If not, were safe practices violated? If so, then were the procedures available, workable, intelligible, correct and routinely used? Would another individual act the same way in a similar circumstance? The answers to these questions guide the evaluation of expectations, systems, and training with the determination of a system failing or an individual behavior problem.

If St. Mary’s Hospital had a strong Just Culture would this event be handled in a different way or could it have been prevented? There are a number of areas to consider. First, Nurse Thao was working extra shifts at a rate the data shows promotes unsafe acts. There should have been a strong policy that prevents nurses from taking on unsafe extra hours of work. The medications looked alike and arrived without a proper order. The newly implemented wrist band bedside medication verification was not working properly and nurses routinely circumvented its use.

An institution with a Just Culture would have quickly followed a standard algorithm and determined that, neither the act nor the consequences were intentional. That substance abuse did not play a role. That despite the fact that clear policies were violated, the training and systems were faulty and that others would have made a similar mistake. Julie Thao’s error might have been a natural result of the institution’s failure to protect the patient with the proper policies and systems. The institutions must accept the blame, work to correct their policies and have a process that aids the involved staff through the period of intense personal guilt and remorse that inevitably follows.

We need to separate the act from the outcome. What if Jasmine Gant had a brief arrhythmia and mother and baby were fine? Would the response be the same? Nurse Thao’s actions would be identical in both circumstances. Would the investigation of the event proceed in a similar manner with the purpose of preventing future similar events?

Could this happen at GBMC? Do we have the systems and processes in place to prevent such an error?

I spoke with Jody Porter, our senior vice-president for patient care services and Sue Bowen, our administrative director of L&D. We reviewed our policies and procedures with regard to epidural medications. Since this episode in Wisconsin, epidural catheter manufacturers have made their catheters a bright yellow. Unfortunately the ends where the medication lines are attached are the same for IV catheters and epidural catheters. Our medications for epidurals are premixed by the pharmacy. The drugs (fentanyl and bupicacaine) are highlighted in yellow and there is a hot pink label (like St. Mary’s) on the bag stating EPIDURAL use. Yellow stickers are placed on the epidural tubing stating “epidural use only”. I visited our labor and delivery suite and spoke to our nurses and one of the anesthesiologists. They showed me how they used the Omnicell for the medication and the special tubing. At our hospital it is the anesthesiologist who actually attaches the medication line to the patient. The antibiotics that are used in L&D are physically much different from the epidural medications as shown. The epidural mixture is on the left with the two antibiotics frequently used to the right. Ampicillin’s vial is attached to the bottom of the infusion saline and Cefazolin is in a foil container.

Nationally, a recommendation by the Institute of Medicine in 2004 to limit nurses' working hours has not been adopted. The institute, a nonprofit organization that advises Congress on health-care policy, said states should prohibit nurses from working more than 12 hours in a 24-hour period or more than 60 hours per week. "No real action has occurred," said Ann Rogers, a nursing professor at the University of Pennsylvania. Her studies have revealed an increase in fatigue and errors among nurses who work more than 12 hours in a row. Our practice is that nurses can only work a maximum of 16 hours in a 24 hour period. The lessons that we can learn are that medicine has the capacity to heal and cure, but also has a capacity to cause great harm. As healtcare providers we must be vigilant in following Hippocrates' first dictum: "first do no harm".