MADISON, Wis. -- A report released this week gives an in-depth look at what happened when a 16-year-old girl who was pregnant died at St. Mary's Hospital after a medical error nearly four years ago.

The report found that problems at the hospital helped lead to the young mother's death during childbirth. Jasmine Gant died in July 2006 after a nurse mistakenly gave the girl an epidural intravenously rather than an antibiotic. Although the girl died, her infant son survived.

While the nurse, Julie Thao, was criminally charged in connection to Gant's death and pleaded to a less charge, she was ultimately held responsible for the error. Her nursing license was temporarily revoked.

However, the report details issues at the hospital as well, WISC-TV reported.

The report was issued in a patient safety journal and was conducted by an independent group and St Mary's officials. It found that there were some systemic problems, including miscommunication between nurses and anesthesiology staff, as well as chronic misuse of hospital drug scanning equipment, which helped lead to Gant's death.

St. Mary's officials said that since then, they've taken taken steps to avert similar situations.

"We've dramatically improved the percentage of medications that could be scanned and we've dramatically improved the use of the system as well," said Frank Byrne, president of St. Mary's Hospital.

The report also said that there were similarities between the packaging of two drugs that were inadvertently switched, and nurses were suffering from fatigue from frequent back-to-back shifts with little time off.

Since Gant's death, St. Mary's officials said that they have taken major efforts to fix problems detailed in the first review done in 2007. The hospital published that review in the hopes of preventing issues at other hospitals.

However, some said there's one issue the hospital hasn't addressed as yet. The author of an editorial critical of St. Mary's treatment of Thao said the hospital hasn't addressed how they'll deal with staff in the future. Dr. Charles Denham, chair of the Texas Medical Institute of Technology, said that he thinks this aspect should be considered in the process.

"I really applaud St. Mary's for their report. The only missing piece was acknowledgement of the 'care of the caregiver' practice which defines how to systematically care for the caregiver after an event," said Denham.

Denham hired Thao as a research fellow in patient safety following her firing from St. Mary's.

St. Mary's officials said that the "care of the caregiver" standard Denham is referring to isn't a universal standard practice, and they do have procedures in place to support employees in this situation.

They've also made efforts to increase communication between disciplines, require nurses to take 12 hours off after double-shifts, changed epidural practices and compliance with barcode practices is now 98 percent, they said.