Followup: Nurse Gets Probation


The Capital Times

Follow up to this original story:

Thao was initially charged in the case with a felony count of causing great bodily harm to a patient by negligence, a charge which came after an investigation by the State Justice Department into the death of Jasmine Gant, who died after being given an epidural by Thao, who should have been administering penicillin, as Gant was about to give birth on July 5.

As I said before, I don't think its right to criminalize a mistake that was at least contributed to by the system she worked in.

During the three years of probation, Thao will be forbidden from working as a critical care nurse in such areas as obstetrics, intensive care or emergency room work.

On Thursday the state Board of Nursing suspended Thao's nursing license for nine months, retroactive to July 6. The board also put several restrictions on Thao's license, including requiring reports from her supervisors and that she teach other nurses on preventing medication and health care errors.

Young, in addressing the court, said there could be a benefit to that.

“Maybe Jasmines death will make a lot of nurses in this world do the right thing for patients,” she said, “instead of taking it on themselves to take shortcuts.”

At least she will be working to teach other nurses (and other hospitals) to prevent mistakes… I hope they use lean methods — root cause problem solving, systems thinking, and error proofing rather than her just going around to tell nurses to “be careful.”

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. My thinking too! It’s the product of a broken system. Don’t punish the poor nurse, fix the system.

    It’s like Deming’s demonstration where he would ask managers to pick only the right colored beads from a mixed bowl, with their eyes shut. When they failed, he would explain that it’s the same situation workers are in with an out-of-control process. Yelling at the workers doesn’t help. Giving them tools so they can see the color of the beads does.

    I guess the D.A. hasn’t heard about that.

    By the way. when is the last time you heard of a doctor facing criminal charges for losing a patient?

  2. In this blog post, there was an article about a doctor merely being SUSPENDED after a third “wrong site” surgery error.

    No jail time for that doc, I assume.


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