Franck Guilloteau starts by describing the circumstances that lead to the death of a 16 year old pregnant woman who was in labour and being looked after by Julie Thao.

After an intense double shift, (16.75 hours) and less than 6 hours of sleep before starting a third shift, Julie was very fatigued. Although appropriately labelled, the infusion bags were identical in size, shape, and connectors. She did not try to use the bar code scanning device on the clear bags because of difficulties she had encountered during the prior 2 shifts with the same type of infusion bags. She inadvertently mixed up the antibiotic and epidural bags and delivered the epidural medication through the patient's intravenous route meant for the antibiotic. When it was discovered that the wrong medication was delivered through the wrong route resulting in the death of a young mother, Julie collapsed and was admitted to the hospital as a psychiatric patient.

In the weeks that followed, she was terminated from her post with no severance compensation and criminally charged by the state attorney general; when she returned to her hospital for pastoral care, she was instructed by an administrative director not to return to the property. During the darkest hours that followed, she felt entirely abandoned, facing the possibility of jail time, a large fine, and loss of her license.

Ultimately, because of the cost of continuing to trial, she pleabargained to accept a conviction of 2 misdemeanours. Thus, she did not have to serve a jail sentence. The board of nursing also concluded their investigation and opted not to revoke Julie's license and to allow her to practice again within a year. However, her life will never be the same after having made a fatal human error that was predisposed by systems failures and human factors. Subsequently, she has been embraced by leaders of the patient safety community to help make her story a learning case that can prevent harm to patients, caregivers, and our hospitals.

For more information regarding human factors:

http://www.riskybusiness.com/