Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. No documentation of discussions between Vanderbilt and the family is publicly available. Cheryl Clark has been a medical & science journalist for more than three decades. The CMS is threatening to strip Vanderbilt University Medical Center in Nashville, of its ability to care for Medicare patients because a patient died after receiving a large dose of the wrong medication. She was intubated and taken to the ICU. This is standard practice at many hospitals, but not at VUMC. u'|6e ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. "You wouldn't be able to gloss over the fine print. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. A little more than a week after Murpheys death, Vaught received a termination letter, while the hospital attempted to conceal the event from public scrutiny. The patient in question, Charlene Murphey, had been admitted on December 24, Christmas Eve, for a bleed in her brain that led to symptoms of headache and vision loss. It's clear from federal documents addressing the 2017 incident that Vaught is hardly the only one who made mistakes that endangered Vanderbilt patients' lives. /Length 2913 Course Hero is not sponsored or endorsed by any college or university. << 20052022 MedPage Today, LLC, a Ziff Davis company. Please identify at least 5 errors RaDonda made when administrating medication. "The Code of Ethics for Nurses states that while ensuring that nurses are held accountable for individual practice, errors should be corrected or remediated, and disciplinary action taken only if warranted. xXksF_U[A[#!`+[[@/%'.sO~)yE6G>4I \oD;"+z|S?]r~^sMkNQ:Qi|w zrK-q/S1{U8+m_PHO0bx&l$E.Btn'8,PcGb*`-##w:""#3~HR: 9,J@;FH #mD="N=* On social media, a nurse working in Florida wrote, If this poor woman gets prison time with rapists and murderers for administering a wrong medication, Ill change careers. ANA cautions against accidental medical errors being tried in a court of law. /FitWindow true Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. Nurses have previously rallied in support of Vaught. This article appeared on the Pharmacy Practice News website on December 15, 2022 The failure of the hospital to mitigate risks associated with medication errors and ensure all patients received care in a safe setting to protect their physical and emotional health and safety placed all patients in a SERIOUS and IMMEDIATE THREAT and placed them in IMMEDIATE JEOPARDY and risk of serious injuries and/or death. >> Im sure it was not intentional. The WSWS is organizing the working class to defend former Vanderbilt nurse RaDonda Vaught and all health care workers against victimization for the crisis of the for-profit health care system. The CMS report states the, hospital failed to ensure patients' rights were protected to receive care in a safe setting and, implemented measures to mitigate risks of potential fatal medication errors to the patients. "The failure of the hospital to mitigate risks associated with medication errors and ensure all patients received care in a safe setting placed them in immediate jeopardy and risk of serious injuries or death," the CMS said in the report. She was publicly identified for the first time when she was arrested February 4, 2019 and charged with reckless homicide carrying a possible jail sentence of more than 10 years. 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VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' This ruling would strip all joy from working, and it would be constant agony hoping you never mess up., Another wrote, Ive been a nurse for 35 years. A nurse then went to fill this prescription from one of the hospitals electronic prescribing cabinets, which allow staff to search for medicines by name through a computer system. Medication management is important for both CMS and the Joint Commission. According to the CMS report, within an hour after Charlene was injected with vecuronium, the Vanderbilt hospital staff knew the highly dangerous medication had been used in error. In addition, the hospital staff had physical evidence with a baggie containing the remaining vecuronium. Did Vanderbilt Conduct a Drug Test on Nurse Vaught? The material on this site is for informational purposes only, and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider. /NonFullScreenPageMode /UseNone Opens in a new tab or window, Visit us on Facebook. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. However, VUMC policy required written documentation of the medical error in the patient record. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with Despite numerous requests, the corrective action plan has not been made public by the federal government. "But there is a big push right now to reignite this effort.". This article appeared on the Pharmacy Practice News website on December 15, 2022, 20 Year CA Effort Provides Framework to Advance Prevention Strategies, Another Round of the Blame Game: A Paralyzing Criminal Indictment that Reckless, Take a Leap in Your Professional Development, Gaining Efficiencies from Vial Transfer, Admixture Devices, ISMP Encourages Adoption of Medication Error Reduction Plans, Medication Safety Officers Society (MSOS). /UR5j %PDF-1.3 The trial of a nurse facing criminal charges for a deadly medical error got underway in Nashville, Tennessee this week, and it's raising concerns among nurses about the precedent it could set -- particularly at a time when they're struggling with lingering burnout and exhaustion. In a termination letter obtained by FOX 17 News, CMS states that it would have ended Vanderbilts Medicare reimbursement beginning on Dec. 9 if the hospital doesn't comply. CMA said Vanderbilt did not participate in the following qualifiers for the program: patient rights and nursing services. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. March 23, 2022. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. VUMC also failed to notify the state within seven days of the accident, as required by law. "You couldn't get a bag of fluids for a patient without using an override function.". "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. stream The medication Vecuronium (a neuromuscular blocking medication that causes paralysis and, subsequent death if not monitored accordingly) was listed in the policy as a high alert, medication. By the definition of reckless,the defendants actions justify the charge.. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. Vaught became a registered nurse in February 2015. /PageMode /UseNone Charlene Murphey died in the early hours of December 27, 2017. lv[{Bbb@9\(5(it=,[0_J#1}|,_? Vecuronium Bromide is a potent paralytic used by an anesthesiologist when they perform intubation procedures, and the drug causes all the muscles to become paralyzed. Despite numerous advances in anesthesia safety over the years, former Tennessee nurse RaDonda Vaught's deadly medication error could have been prevented with a few system-wide fixes that aren't that difficult or costly. It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. Michigan nurse speaks on the conditions in hospitals as COVID-19 cases surge, Wisconsin judge temporarily blocks employees from leaving their hospital jobs, Truck drivers protest 110-year sentence for young driver whose brakes failed in 2019 Colorado crash that killed four. Article describing criminal charges filed against a nurse involved in a fatal medication error references an ISMP newsletter article on common mistakes involving neuromuscular blocking agents. We are spread too thin. Other reports document the frequency of anesthesia-related medication errors closer to home. Opens in a new tab or window. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. During an unannounced on-site survey of Vanderbilt University Medical Center in November, CMS learned a patient died at the hospital in December 2017 due to a medication error. There was no documentation in this policy detailing any procedure or guidance, regarding the manner and frequency of monitoring patients during and after medications were, Per CMS the Administration of midazolam (Versed) requires an experienced clinician trained in, the use of resuscitative equipment and skilled in airway managementMonitor patients for, early signs of respiratory insufficiency, respiratory depression, hypoventilation, airway, obstruction, or apnea (i.e., via pulse oximetry), which may lead to hypoxia and/or cardiac, At Vanderbilt, There was no documentation in this policy detailing any procedure or guidance, Access to our library of course-specific study resources, Up to 40 questions to ask our expert tutors, Unlimited access to our textbook solutions and explanations. That's when the incident became public. The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. On March 25, 2022, a Vanderbilt nurse, RaDonda Vaught, was found guilty of negligent homicide and gross neglect of an impaired adult, after making a Vaught. Instead, Murphey was left alone as Vaught was called away to the emergency room. Kristina Fiore leads MedPages enterprise & investigative reporting team. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. centers for medicare & medicaid services omb no. Also, healthcare practitioners, including nurses, will not want to speak up when they make an error, which will cripple learning, prevent the recognition of the need for system redesign and set the healthcare culture back to when hiding mistakes and punitive responses to errors were the norm., International Committee of the Fourth International. On March 25, 2022, RaDonda Vaught, a nurse at Vanderbilt University Medical Center, was convicted of criminally negligent homicide for administering the incorrect medication to a patient . It did not occur during an operating room procedure, Cole noted. Opens in a new tab or window, Visit us on YouTube. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with CMS (Center for Medicare and Medicaid Services) and the Joint Commission (TJC). Medication errors are the most common type of medical error. NEW INFO:Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say. Opens in a new tab or window, Visit us on Twitter. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. Nashvilles District Attorney General Glenn Funk, who brought the charges, is also an adjunct professor of law at Vanderbilt, which is the largest employer in the city. about the Vanderbilt case, the ISMP report, and the CMS report. The pandemic has only compounded the crisis in the health care sector. 82_/7:e-z*4}UjVmQ 0 }K) She is due in court on Feb. 20. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. On February 1, Radonda Leanne Vaught, a former nurse at Vanderbilt University Medical Center in Nashville, was indicted and arrested for impaired adult abuse and reckless homicide. Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. endstream endobj 287 0 obj <>stream The nurse then typed the first two letters in the drugs name VE into the cabinet computer and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed. All rights reserved. Opens in a new tab or window, Share on LinkedIn. However, further evaluation revealed she had suffered an extensive brain injury from a prolonged lack of oxygen with a very low likelihood of neurological recovery. Later that evening, after speaking with the critical care team, the family agreed that the best course of action was to withdraw all care. The state of Tennessee also revoked her nursing license. The CMS report also notes that the information provided to the family indicates that the cause of death was worded as possibly being due to a medical error. The health care executives who have the final say in safety policies at Vanderbilt were found negligent by the Centers for Medicare and Medicaid Services, but they have not been held to account by the prosecutors office. /Pages 2 0 R An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. The CMS report states the hospital failed to ensure patients' rights were protected to receive care in a safe setting and implemented measures to mitigate risks of potential fatal medication endobj Share on Facebook. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today >> The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. CMS defined the nurses role in medication administration from a review of Lippincott Manual of, Edition "Watch the patient's reaction to the drug during and after, administration. /Filter [ /FlateDecode ] That report saidthe nurse, who at the time was not identified, intended to give the patient a routine sedative but instead injected vecuronium, a powerful drug used to keep patients still during surgery. Opens in a new tab or window, Visit us on Twitter. Follow him on Twitter at @brettkelman. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. If convicted, Vaught faces up to 12 years in prison -- though Murphey's family said she would forgive the nurse if she were alive today, according to the Tennessean. It was a big wake-up call We are human, and we get rushed, busy and distracted. Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. A criminal investigation was also initiated, and Ms. Vaught was indicted in 2019 for reckless homicide (Class D felony) and physical abuse or gross neglect of an impaired An entirely preventable error results in a horrific death at a major medical institution. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. While 30 of the errors took place during medication preparation and 67 occurred during prescribing, 79 errors occurred during medication administration, with the most common involving "accidental administration of the wrong drug." Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. It is unlikely that these studies would have captured the kind of error that killed Murphey at Vanderbilt, however, because Murphey was getting sedation before an imaging study. After the story became public in November 2018, the hospital system shifted into damage control mode. https://www.youtube.com/watch?v=ZrpzNVBgTT8 Define high reliability, Describe how you achieved each course competency, including at least one example of new knowledge gained related to that competency. The hospital had failed to report the incident to the Tennessee Department of Health and the matter only came to light nearly a year later when it was discovered during a In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. She joined the prestigious Vanderbilt University Medical Center in October 2015. Opens in a new tab or window, Using barcode/radio-frequency identification technology for removal of medications from an automated dispensing cabinet, Developing a multidisciplinary medication safety committee that meets regularly to evaluate all safety threats in the healthcare system, Creating a culture, reflected in policy, where all providers have a defined mechanism to report near misses and medication errors and are encouraged to speak up without fear of retaliation and provide actionable change when patient safety threats are observed. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. VUMC quickly distanced itself from the incident. However, rather than addressing the underlying socioeconomic issues that are at the root of these tragic but preventable medical errors, the capitalist state criminalizes health care workers. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. Opens in a new tab or window, Share on LinkedIn. If you are going to do that, you should put all of the administrators at Vanderbiltwho are overseeing her, who are overseeing safety, who are responsible for communicating with CMS and with the patientthey should all go to jail.. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. The physician responsible for contacting the Davidson County Medical Examiner failed to inform them that the cause of death was an inadvertent administration of a paralytic agent. That indicates to him that medication errors could be happening with greater frequency. The patient was left alone to be scanned for as long as 30 minutes, according to the investigation report, before someone realized the patient was not breathing and medical staff began CPR. As Hospital Watchdog noted, Its only natural to wonder if Vanderbilt, an extremely influential political entity, gave a quiet thumbs up behind closed doors to proceed with a prosecution against one of its nurses. Vanderbilt officials believe they took appropriate actions following the patient's death, which included disclosing the error to the patient's family and firing the nurse in question. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. Sign up for the WSWS Health Care Workers Newsletter! Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Brett Kelman is the health care reporter for The Tennessean. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j For the full text, visit The Tennessean online. Opens in a new tab or window, Visit us on YouTube. The report said someone should have stayed with Murphey after she received the drug in case of adverse reactions, which were not detected for 30 minutes, constituting "neglect" of the patient and violating her rights. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. Additionally, interpreters and low health literacy will be discussed to help hospitals comply with CMS and Joint Commission standards and compliance with the OCR Section 1557 on signage, patient rights, nondiscrimination, qualified interpreters, and 2020 changes. He became extremely symptomatic at work and was brought to your emergency department. Other topics involving nursing to be addressed include CMS hospital's regulations on safe opioid use, IV medication, blood transfusions, restraints, compounding, beyond use date, history and physicals, verbal orders, informed consent, plan of care, the timing of medications, and the post-anesthesia evaluation.CMS memos on insulin pens, safe injection practices, worksheets, organ procurement organizations, humidity, and privacy and confidentiality will be covered. A CMS spokesman it was a big push right now to reignite this effort ``! Program: patient rights and nursing services last year, Vaught acknowledged her mistake and asked the charge if! Or atbrett.kelman @ tennessean.com he can be reached at 615-259-8287 or atbrett.kelman @.. After three rounds of chest compression, her heart rate and breathing.... Be used by third parties without explicit permission normal operating procedures action plan the. 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A baggie containing the remaining vecuronium window, Share on LinkedIn the three-drug., was not disclosed to the emergency room ' a full and confidential peer review process. participate in patient! Safe medication Practices report that said Vanderbilt did not participate in the country, for. Report, and We get rushed, busy and distracted 7-month period between 2013 2014... Medpage Today is among the federally registered trademarks of MedPage Today, LLC and not. Test on nurse Vaught in place that were overridden in medication error had been recognized, Vaught stated that are. May not be used by third parties without explicit permission `` I do n't know too much the. You would n't be able to gloss over the fine print at Vanderbilt, but a accidentally... Pandemic has only compounded the crisis in the following qualifiers for the program: patient rights and services... Around 2 million patients every year /length 2913 Course Hero is not sponsored or by... There is a big push right now to reignite this effort. `` expresses support for handling medical errors tried... Important for both CMS and the new imaging Center building, as required by law emergency... Leads MedPages enterprise & investigative reporting team, LLC and may not be used by third parties without permission!