There is a second tragedy at St. Mary’s Hospital that is
scarcely hinted at in the otherwise excellent report by
Smetzer et al. of the investigation and response to a terrible fatal
medication error.1 That tragedy is what happened to the nurse
who made the error, Julie Thao, whom the hospital blamed for
the mishap and fired. Not only was this action calamitous for
Julie, but if the hospital had taken institutional responsibility at
the outset, the criminal indictment and loss of licensure might
not have occurred. Julie was truly a second victim in more ways
than one....
,,Because, as the mantra since the Institute of Medicine
report To Err Is Human 2 insistently reminds us: Errors and
mishaps are caused by bad systems, not by bad people. Who is
responsible for the systems? The hospital. Individual frontline
caregivers—doctors and nurses—do not create or change systems,
the organization does.
