The hospital's physicians also failed to notify state or federal officials of the error or the unexpected death, which they were obligated to do. Article describing criminal charges filed against a nurse involved in a fatal medication error Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. 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." That indicates to him that medication errors could be happening with greater frequency. 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. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). 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. against Nurse Vaught. >> 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. 2023 www.tennessean.com. An IOM study found that a hospital patient is subject to one medication error per day. Follow him on Twitter at @brettkelman. She searched "VE" again and the cabinet produced the paralytic vecuronium. h222U0Pw/+Q0L)62)IXTb;; `t VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. The incident and Vaught's involvement did not become public for almost a year, until an anonymous tip the following October prompted an unannounced federal inspection. The CMS investigation also notes that Vaught was talking to another person whom she was supposed to be orienting while she was typing the medication into the system. All rights reserved. Cheryl Clark has been a medical & science journalist for more than three decades. 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 At Vanderbilt, "the override function allows the nurse to remove a medication from the machine before a pharmacist reviews the order," the CMS report stated. /Filter [ /FlateDecode ] VUMC quickly distanced itself from the incident. "Yes, we have lost some mojo, the pandemic being one reason," he said. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. "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. In VUMC also failed to notify the state within seven days of the accident, as required by law. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. 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.. RaDonda Vaught, 38, was charged in 2019 with reckless homicide and impaired adult abuse after she allegedly gave 75-year-old Charlene Murphey the paralytic vecuronium when she was meant to give her the sedative midazolam (Versed) for her anxiety ahead of a PET scan. 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. ANA maintains that this tragic incident must serve as reminder that vigilance and open collaboration among regulators, administrators, and health care teams is critical at the patient and system level to continue to provide high-quality care.". Opens in a new tab or window, Visit us on Facebook. 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. 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. %PDF-1.6 % Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. The medical examiner told federal investigators that the office "released jurisdiction (did not investigate the death or perform an autopsy on patient Murphey) because there was an MRI that confirmed the bleed." And this has just set us back.". Despite the requirement that the county medical examiner be notified in the case of unusual or unexpected deaths -- which many patient safety advocates say would detect fixable hospital errors and provide accountability -- hospital officials instead attributed her death to her brain bleed rather than a medication error. Share on Facebook. The CMS investigation also notes that Vaught was talking to another person whom she was supposed to be orienting while she was typing the medication into the system. Institute for Safe MedicationPractices All rights reserved. stream Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. 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 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. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. 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 5 0 obj The pandemic has only compounded the crisis in the health care sector. 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. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. /PageLayout /SinglePage It did not occur during an operating room procedure, Cole noted. Medication Error Kills A Vanderbilt Patient | Incident Report 203 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. 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. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. 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. MH magazine offers content that sheds light on healthcare leaders complex choices and touch pointsfrom strategy, governance, leadership development and finance to operations, clinical care, and marketing. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. 82_/7:e-z*4}UjVmQ 0 }K) #xsc+EX:e| Brett Kelman is the health care reporter for The Tennessean. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. Of 2,087 adverse events reported during more than 2.3 million anesthetic administrations, it found 276 medication errors -- the third highest category of events next to cardiac and respiratory events. Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. It also states that the trial will be watched closely by nurses across the U.S., who are worried that a conviction may set a precedent -- particularly at a time when nurses are exhausted and demoralized, which can make them more prone to error. 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. March 23, 2022. 286 0 obj <>stream An entirely preventable error results in a horrific death at a major medical institution. by 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. u'|6e This isn't Versed. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. 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. She died one day later after being taken off of a breathing machine. "The facility no longer meets the requirements for participation as a provider of services in the Medicare program," the CMS said in a letter this month to Chad Fitzgerald, regulatory officer at Vanderbilt University Medical Center. 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 about the Vanderbilt case, the ISMP report, and the CMS report. 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. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. /UR5j 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. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. "That's the kind of culture that we're trying to improve. ANA cautions against accidental medical errors being tried in a court of law. Vaught, 36, of, 1. Identify, Review the zDogg videos(Links to an external site.) 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. 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. As Vaught explained, Overriding was something we did as a part of our practice every day. 5200 Butler Pike 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. % centers for medicare & medicaid services omb no. endstream endobj 288 0 obj <>stream Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. I knew if I wanted to become a subject matter expert and advance through the ranks of medication safety specialists, I needed to align myself with the organization considered the gold standard for medication safety information. Im so sorry for this nurse and the patient.. Other reports document the frequency of anesthesia-related medication errors closer to home. 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. ) the second nurse asked the first nurse, showing her the baggie, according to the report. 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. Medication management is important for both CMS and the Joint Commission. However, The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. /NonFullScreenPageMode /UseNone She was intubated and taken to the ICU. 20052022 MedPage Today, LLC, a Ziff Davis company. But as part of the correction plan, to save face with the public, Vaught was singled out for blame. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. 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 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. This is every nurses nightmare. "But there is a big push right now to reignite this effort.". 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. 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. "You wouldn't be able to gloss over the fine print. Im sure it was not intentional. A third strategy, he suggested, is for organizations to make sure their institutional culture does not "enable normalization of deviance," by which nurses and other practitioners normalize the process of finding workarounds, such as overriding safety blocks, to get things done. 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. Opens in a new tab or window, Visit us on LinkedIn. A second nurse found a baggie that was left over from the medicationgiven to the patient. All rights reserved. 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. The nurse who administered the drug was fired. 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. 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). Opens in a new tab or window, Visit us on YouTube. >> Vaught, who is out on bail, has declined to comment. I made a bad medication error 17 years ago and nearly killed a patient. State surveyors made an unannounced visit to the academic medical center late last month and learned that a patient died after receiving not only the wrong medication, but a high dose of the errant drug as well, according to a report given exclusively to Modern Healthcare by the CMS. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. According to an inspection report given to Becker's Hospital Review by CMS, the patient was suffering from hematoma of the brain, headache and other related symptoms 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 Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. Over the next two days, her condition improved. 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. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today 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. 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. Opens in a new tab or window, Visit us on Twitter. 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 . WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. 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. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. 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. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. Opens in a new tab or window. 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. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. If you value in-depth reporting about the issues in our community, please support our work by subscribing. 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. For the full text, visit The Tennessean online. 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. She is due in court on Feb. 20. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. Have an opinion about this story? In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 Cheryl Clark, Contributing Writer, MedPage Today We [the medical examiner] didn't see any red flags.". In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. Please identify at least 5 errors RaDonda made when administrating medication. endstream endobj 287 0 obj <>stream Opens in a new tab or window, Visit us on Facebook. 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. Share on Facebook. 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. 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. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. 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. If their plan fails to meet CMS standards, the hospital could lose its Medical (Vanderbilt Medical Center Photo by: Neil Brake)FeatureStand AloneSpring, 'Most childrens hospitals are struggling,' says John Nickens, president and CEO of Children's Hospital New Orleans, More healthcare organizations at risk of credit default, Moody's says, Centene fills out senior executive team with new president, COO, SCAN, CareOregon plan to merge into the HealthRight Group, Blue Cross Blue Shield of Michigan unveils big push that lets physicians take on risk, reap rewards, Bright Health weighs reverse stock split as delisting looms. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. 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. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. Despite numerous requests, the corrective action plan has not been made public by the federal government. "The error occurred because a staff member had bypassed multiple safety mechanisms that were in place to prevent such errors," said Vanderbilt Spokesman John Howser. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. This is standard practice at many hospitals, but not at VUMC. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. But the trial is a vicious effort at scapegoating her to put all the responsibility for the tragedy on her shoulders and save the reputation of Vanderbilt, one of the major medical facilities in the South. Opens in a new tab or window, Visit us on Instagram. 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. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. endstream endobj 289 0 obj <>stream 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. 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. Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. 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. Are you a nurse? by Charlene Murphey died in the early hours of December 27, 2017. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. Opens in a new tab or window, Share on Twitter. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. ~sV The patients primary nurse was not available at the time. 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. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. 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. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. /Length 2913 As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. Plymouth Meeting, PA 19462. Public records list Murphey as a 75-year-old resident of Gallatin. /ViewerPreferences << Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". 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. However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. Is this the med you gave (the patient? The most common ones involved opioids or sedative/hypnotics. 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. 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt 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. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. 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 statement expresses support for handling medical errors with 'a full and confidential peer review process.' All rights reserved. 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. "We will continue to work closely with representatives of Tennessee Department of Health and (the CMS) to assure that any remaining concerns are fully resolved within the specified time frame.". 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. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. She was told it was unnecessary and that the electronic medication administration would automatically record it. No The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. This article appeared on the Pharmacy Practice News website on December 15, 2022 Opens in a new tab or window, Share on LinkedIn. Contact the WSWS with your story on conditions in the hospitals. 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. 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. 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. We are spread too thin. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. 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. And the results of such a mistake can be devastating, according to the institute article, Paralysis starts small, likely with the face or hands, then spreads throughout the body until all muscles are frozen and the patient can no longer breathe. By the definition of reckless,the defendants actions justify the charge.. After the story became public in November 2018, the hospital system shifted into damage control mode. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! No documentation of discussions between Vanderbilt and the family is publicly available. receiving care in the hospital (CMS, 2018, p. 1). inadvertently injecting a patient with a deadly dose of a paralyzing drug, Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say, Victim would forgive nurse who mixed up meds, son says, Vanderbilt didnt tell medical examiner about deadly medication error, feds say, Your California Privacy Rights / Privacy Policy. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. Opens in a new tab or window, Visit us on TikTok. Vanderbilt University Medical Center (FOX 17 News) NASHVILLE, Tenn. (WZTV) A Vanderbilt nurse made a deadly error and now the hospital has taken steps to ensure it hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j >> /FitWindow true hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* Beyond the personal aspects of these events, the prosecution of the nurse is sending waves of resentment among nurses who fear the trial will set a precedent. 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. 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. In a new advisory, the organization recommends that leaders make changes so mix-ups and missteps like those that killed 75-year-old Vanderbilt University Medical Center patient Charlene Murphey are nearly impossible. 2023 www.tennessean.com. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! 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. 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. 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. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. 2023 Institute for Safe Medication Practices. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. John Howser, chief communications officer at VUMC, claimed, We disclosed the error to the patients family as soon as we confirmed that an error had occurred. However, according to Gary Murphey, Charlenes son, The family had never been informed by the hospital that the medication Vecuronium caused [my] mothers death.. It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. The agency spent days questioning Vanderbilt personnel and found problems so serious, it threatened to revoke the system's Medicare reimbursement unless it took corrective action. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. Follow. "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. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. Medication errors are the most common type of medical error. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. 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. Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. Sign up for the WSWS Health Care Workers Newsletter! It's vecuronium.". ", 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.". See who else is going to Nursing & Law Navigating Problematic Nursing Chapter Standards with CMS TJC, and keep up-to-date with conversations about the event. 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. Opens in a new tab or window, Share on LinkedIn. Questions 1. 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. The patient died in December 2017 but surveyors said they did not find evidence that Vanderbilt had put procedures in place to ensure such an occurrence wouldn't happen again. 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. 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. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. The cost of these errors amounts to about $40 billion each year. Testimony has begun in the trial in Nashville, Tennessee, of a former Vanderbilt University Medical Center (VUMC) nurse, RaDonda Vaught, for the death of a 75-year-old woman, Charlene Murphey, in late 2017. 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. Opens in a new tab or window, Visit us on Instagram. Opens in a new tab or window, Visit us on LinkedIn. 2. Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. %PDF-1.3 Click here to submit a Letter to the Editor, and we may publish it in print. The article entitled Paralyzed by Mistakes said that neuromuscular blocking agents like vecuronium have a well-documented history of causing catastrophic injuries or death when used in error. The article goes on to say that the most common error involving these drugs is accidental medication swaps, which are often caused by documents with look-alike names. The article specifically cites vecuronium as a dangerous drug that can be easily confused others. 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. anthony from intervention died, tabitha ransome, wimberley football schedule 2021, how did christianity change societies in latin america dbq answer, chemical bank mobile deposit funds availability, lewis and clark graduation 2022, nelly shepherd back lump, north american opossum sounds, is ivan cleary related to michael cleary, tin lizzie model t go kart for sale, iomega drivers windows 10, june 6 birthday zodiac sign, huntington state beach lifeguard tower map, large scrapbook photo album, discrete and continuous word problems, Of our practice every day died in the country, caring for around 2 million patients year! Adults along the continuum of care in the country, caring for around 2 million patients every.! 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