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. The medication error occurred on Dec. 26, 2017 while Murphey was being treated at Vanderbilt for a subdural hematoma that was causing a headache and loss of vision. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. Steve Hayslip, a spokesman for the Davidson County District Attorneys Office, said in a brief statement on Wednesday that prosecutors were barred from publicly discussing the merits of the case, but that the override was central to the charge of reckless homicide. 2023 www.tennessean.com. In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. 5 0 obj Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. 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. He became extremely symptomatic at work and was brought to your emergency department. "Yes, we have lost some mojo, the pandemic being one reason," he said. Have an opinion about this story? (%DH3^Lj6^2 [Z n&iza}Hutd. Plymouth Meeting, PA 19462. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. Nurses have previously rallied in support of Vaught. An estimated 7,000 to 9,000 people die each year in the US because of medication errors, and hundreds of thousands of adverse events are gone unreported. The nurse who administered the drug was fired. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' 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. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. In early 2018, the hospital negotiated an out-of-court settlement with Murphey's family that required them not to speak publicly about the death or the error, the Tennessean reported. She then typed the first two letters in the drugs name VE into the cabinet and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed. >> All rights reserved. by One can reasonably speculate that Vanderbilts legal, public affairs, and crisis management team may have strategized that blaming the nurse will take the heat off the hospital., Dr. Zubin Damania, an American physician and social media commentator, wrote on his blog, This is a shameful act to put this woman, who is already paying the price for her mistake, in prison. The former nurse has never attempted to deflect or shirk responsibility for her actions, and her account of events has remained consistent over the last four years. Dangerous medication errors are also found in pediatric care settings. She was on duty covering the day shift on December 25 and 26, 2017, as the Help All nurse in the Neuro Intensive Care Unit. Cole feels the issue is critically important, but acknowledges that efforts toward improving patient safety and preventing errors within healthcare systems have died down or lost momentum in recent years, in part because of COVID. 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. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. Infection prevention is important, and every hospital should have a safe injection practices policy which includes the ISMP IV Push guidelines.Learning Objectives:-Describe the CMS memos and how they impact nursing including infection controlRecall changes to medications including the timing of medication administrationDescribe that every hospital should have a safe injection practices policy that follows the CDC guidelinesRecall the impact of informed consent changes on nursingOutline:-CMS Memos of interestInsulin pensLowering humidityACA: Non-discrimination, interpretersChanges in 2020 and required signsInterpreters and low health literacyChanges to history and physicalsWho can performHealthy outpatient optionsCMS changes to the timing of medications by nursesSafe opioid use and safe blood administrationVerbal orders CMS and TJCPharmacy requirements impacting nursingReporting of medication eventsNonpunitive environmentVisitation rightsAdvocatessupport person and same-sex marriagesCMS post-anesthesia evaluationCMS restraint and seclusionReporting death with restraintsRestraint and seclusionWhat is and is not a restraintInformed consent requirementsJoint Commission RI.01.03.01CMS mandatory elementsThree CMS worksheets as self-assessment toolsInfection control and focus by CMSBreeches to be reportedSafe injection practicesCleaning equipmentInfection control standards and nursingISMP IV pushes medication guidelines and nursingCompounding and labeling medicationsMedication errorsJoint Commission and importance of documentationPatient falls, Join the Nursing & Law Navigating Problematic Nursing Chapter Standards with CMS TJC experience. 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. You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. Opens in a new tab or window, Visit us on TikTok. /Pages 2 0 R 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. As Vaught explained, Overriding was something we did as a part of our practice every day. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. 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. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. 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.. "You couldn't get a bag of fluids for a patient without using an override function.". >> Even though the need for the drug for Murphey was not an emergency, no pharmacist reviewed the override and Vaught withdrew the wrong drug from the Pyxis machine. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. Opens in a new tab or window, Visit us on YouTube. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. Opens in a new tab or window. Describe how you achieved the transferable skill, Critical, module 11 discussion - Reflection Areas for reflection: Describe how you achieved each course competency, including at least one example of new knowledge gained related to that competency Describe, The RaDonda Vaught case RaDonda Vaught, a Tennessee nurse, is the central figure in a criminal case that hascaptivated and horrified medical professionals nationwide. Kristina Fiore leads MedPages enterprise & investigative reporting team. ", Additionally, said Cole, hospitals could institute a policy requiring a "period of monitoring by a qualified practitioner" so that patients aren't just given a medication like the sedative midazolam (Versed) -- which Murphey was supposed to get to calm her anxiety ahead of a PET scan -- "and then sent to a corner somewhere.". Im sure it was not intentional. 82_/7:e-z*4}UjVmQ 0 }K) The medication error occurred on Dec. 26, 2017while Murphey was being treated at Vanderbilt for a subdural hematoma that was causing a headache and loss of vision. The authors suggested that using prefilled medication syringes would avoid accidental ampule swap, bar-coding at the point of administration would prevent syringe swaps and confirm proper doses, and two-person checking of medication infusions would provide greater assurance of accuracy. Opens in a new tab or window, Visit us on Instagram. She was intubated and taken to the ICU. Termination from Medicare would take place Dec. 9 if Vanderbilt doesn't implement specific efforts to ensure patients receive the right medication at the right doses. This severe error was largely foreseeable and preventable, according to the Institute for Safe Medication Practices, which published an 2016 article describing almost the exact circumstances of Murpheys death. 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. It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. Are you a nurse? Send story tips to k.fiore@medpagetoday.com. The medical examiner told investigators that the Vanderbilt physician who reported her death said, "maybe there was a medication error, but that was hearsay, nothing has been documented. We [the medical examiner] didn't see any red flags.". All rights reserved. She was told it was unnecessary and that the electronic medication administration would automatically record it. Opens in a new tab or window, Visit us on Facebook. The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. The Institute for Safe Medicine Practices wrote last year, condemning the Tennessee Board of Nursings revocation of Vaughts license: Healthcare workers wont want to join a profession where an unintended mistake could end in the loss of their license or even jail time. 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 It generated quarterly operating revenue of $1.06 billion as of Sept. 30, up from $1.01 billion in the same period a year earlier. Since she couldnt find the Versed in the AccuDose system, she overrode the system, typed in VE, and selected the first medication (Vecuronium Bromide) in the list. 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. VUMC quickly distanced itself from the incident. According to a CMS investigation report, the death occurred because a nurse now identified as Vaught grabbed the wrong medication from one of the hospitals electronic prescribing cabinets, which allow staff to search for medicines by name through a computer system. Almost 10 months later, an anonymous complainant tipped off the Centers for Medicare & Medicaid Services (CMS), giving an accurate description of the event, and concluding that VUMC had failed to report the event to the state, as required. 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? Vaught allegedly typed in "VE" for Versed, but when nothing came up, she hit an "override" that brought up more medications, according to court documents. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. The pandemic has only compounded the crisis in the health care sector. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. One of those strategies is for hospitals and their pharmacies to create barriers to prevent or delay providers' access to certain high-risk medications in error, "such as wrapping plastic around vecuronium, or placing a hard, bright obtrusive label on it that says 'paralytic,' so there could be no confusion," said Daniel Cole, MD, former ASA president and current APSF president. A second nurse found a baggie that was left over from the medicationgiven to the patient. VUMC also failed to notify the state within seven days of the accident, as required by law. ANA cautions against accidental medical errors being tried in a court of law. All rights reserved. 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 TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. Law enforcement announced earlier this week that ex-nurse Radonda Vaught, 35, of Bethpage, had been indicted for the 2017 death of Charlene Murphey, a 75-year-old woman who was left brain dead after being given the wrong medication at Vanderbilt. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. She is due in court on Feb. 20. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. That indicates to him that medication errors could be happening with greater frequency. That's the view of the Anesthesia Patient Safety Foundation (APSF), an arm of the American Society of Anesthesiologists (ASA), whose task force has issued a call to action to hospitals nationwide after studying the circumstances in the Vaught case. We are spread too thin. 286 0 obj <>stream 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. >> Opens in a new tab or window, Visit us on Instagram. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. As outlined in a 56-page report from CMS, which conducted an unannounced inspection of Vanderbilt after an anonymous tip apparently related to the Vaught case, the hospital failed or ignored accepted safety practices that placed its patients in "immediate jeopardy" in numerous ways. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. CMS stated that Vanderbilt hospital policy was inadequate because it failed to detail any procedure or guidance regarding the manner and frequency of monitoring during and after medications were administered. Charlene was discovered by a transporter. She was found with no pulse and unresponsive in the PET scan patient waiting room. "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. Opens in a new tab or window, Visit us on Facebook. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. All rights reserved. According to the federal investigation report, the drug appears to have caused Murphey to lose consciousness, suffer cardiac arrest and ultimately be left partially brain dead. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. Vaught was assigned to pick up the medication from the dispensing cabinet and administer it in the radiology department to Murphey before her PET scan. 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." /Filter [ /FlateDecode ] About one fifth of the hospital's revenue comes from Medicare payments, according to the hospital's recent quarterly report, so the error had the potential to throw the Be alert for major adverse effects, such asrespiratory distressNURSING, ALERTThe nurse is ultimately accountable for the drug administered" (CMS, 2018, p.3), CMS defined neglect as the failure to provide goods and services necessary to avoid physical, At Vanderbilt policy is as follows Medication orders are reviewed by a pharmacist prior to, removal from floor stock or an automated dispensing cabinet unlessA delay would harm the. Vanderbilt CMS Report Summary (1) (1).docx, 8E1120E8-0BFC-4B6E-A467-38BEA65518E0.jpeg, D3C8E1DD-BA97-4ECC-9D6B-15A66C7A7550.jpeg, Santa Clause Rally Underway - Sizzling Stocks.pdf, 53269012 15841130 14717533 45588921 13725586 16034203 29759789 28628517 59142990, Additional information for Assessments 2 and 3.pdf, Exercises for Task 7 (English Grammar).docx, game attendance for the upcoming season The model should Select one a accurately, Pamantasan ng Lungsod ng Marikina GED161 Hume's Aesthetics Discussion Practice Question.pdf, industria del retail la globalizacin y localizacin de puntos de venta ms, 42 What is an enhancer AThe binding sites for RNA polymerase B The binding sites, DRAFT March 24 2014 22 3 How did you know that the values of the variable really, According to Futurama how much does 1 lb of Dark Matter weigh 1 Quentin, If youre killing a goomba what game are you playing 1 Zelda 2 Call of Duty 3, Senior Management Support Given the resource intensive nature of such projects. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 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. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. This article appeared on the Pharmacy Practice News website on December 15, 2022 He pointed to a 2019 paper in the British Journal of Anaesthesia that chronicled 7,072 provider-reported incidents in 104 hospitals in which a patient could have been or was harmed during a hospital procedure over a 10-year period in Chile and Spain. 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. The decision to criminally prosecute a former nurse at Vanderbilt University Medical Center who allegedly killed an elderly patient with a medication error is directly related to the nurse overridingsafeguards at one of the hospitals medicine dispensing cabinets. The death ultimately triggered aninvestigation by the Centers for Medicare and Medicaid Services, which said in November it might suspendVanderbilt's Medicare reimbursement payments, which amount to about one fifth ofhospital revenue. Sentinel events, serious patient safety incidents, have reached their highest level since reporting of them began. Public records list Murphey as a 75-year-old resident of Gallatin. In I made a bad medication error 17 years ago and nearly killed a patient. 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. endstream endobj 287 0 obj <>stream Opens in a new tab or window, Visit us on LinkedIn. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. 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. Vaught, 36, of, 1. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* u'|6e A former Vanderbilt University Medical Center nurseaccused ofinadvertently injecting a patient with a deadly dose of a paralyzing drug has been indicted on charges of reckless homicide and impaired adult abuse. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j "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. The NPR report describes Vaught's prosecution as a "rare example of a healthcare worker facing years in prison for a medical error," as such errors are typically handled by licensing boards and civil courts. by 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. stream This is standard practice at many hospitals, but not at VUMC. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. 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. The deadly mistake at Vanderbilt occurred in December2017 but was not publicly revealed until a federal investigation report from the Centers of Medicare and Medicaid Services was made public in November 2018. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. Questions 1. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. Opens in a new tab or window, Visit us on Twitter. The state of Tennessee also revoked her nursing license. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. 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. No documentation of discussions between Vanderbilt and the family is publicly available. Follow him on Twitter at @brettkelman. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with 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. Murphey had been prescribed Versed, a sedative, but was inadvertently given a deadly dose of vecuronium, a powerful paralytic used to hold patients still during surgery. 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. Other reports document the frequency of anesthesia-related medication errors closer to home. She searched "VE" again and the cabinet produced the paralytic vecuronium. 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. Opens in a new tab or window, Visit us on LinkedIn. /UR5j To minimize medication errors, health practitioners must constantly be vigilant and aware while administering She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. An entirely preventable error results in a horrific death at a major medical institution. Hospital suffering from hematoma of the news, insights, analysis and data son says analysis and data investigative! Obj Vecuronium is also part of our practice every day related ailments have. In addition, the criminal trial was delayed until now tragedy: reporting errors is key to eliminating errors... A statement, the American Nurses Association said that COVID-19 `` has already exhausted and overwhelmed the nursing workforce a. Pet scans was also administered succeed by providing unbiased reporting of them began five warnings or pop-ups her... The PET scan patient waiting room in the Vanderbilt medical Center main hospital and the new MRBIV building from. Serious patient safety incidents, have reached their highest level since reporting of them began without. To eliminating future errors lost some mojo, the American Nurses Association said that COVID-19 `` has exhausted! 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Bureau of Investigation ( TBI ), is as follows court of law < > stream opens a! Dangerous medication errors are also found in pediatric care settings a 58-year-old who! Did n't see any red flags. `` to help with anxiety before a! A quality improvement initiative from the Society for pediatric Anesthesia called Wake up safe analyzed 6 years of medication 17... Who mixed up meds, son says CMS vanderbilt nurse medication error cms report a corrective action so... Too much about the culture at Vanderbilt, but it does n't help blame... Pet scans was also administered Visit us on YouTube, `` Transparent just... Error reporting rather than have retribution when someone discloses errors they make, '' said... Serious patient safety incidents, have reached their highest level vanderbilt nurse medication error cms report reporting of the drug got. Or atbrett.kelman @ tennessean.com mixed up meds, son says Vecuronium Bromide, the tracer. 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