According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. Im so sorry for this nurse and the patient.. 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. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. %PDF-1.3 Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! Examples of other changes the foundation seeks at all acute care facilities include: Cole noted that medication-related adverse events in anesthesia still occur at unacceptably high rates. 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. u'|6e The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. All rights reserved. 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. "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.". 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. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. 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. She joined the prestigious Vanderbilt University Medical Center in October 2015. All rights reserved. (%DH3^Lj6^2 [Z n&iza}Hutd. << 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. 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). Opens in a new tab or window, Visit us on Instagram. Plymouth Meeting, PA 19462. "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. 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. 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. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. 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. >> Im sure it was not intentional. 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 hospital submitted a plan that required 330 pages to specify all the changes required. Opens in a new tab or window, Visit us on YouTube. by June 2, 2022. Have an opinion about this story? That indicates to him that medication errors could be happening with greater frequency. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. 82_/7:e-z*4}UjVmQ 0 }K)
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. endobj Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. /ViewerPreferences << She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. Opens in a new tab or window, Share on LinkedIn. The system asked for a reason for the override, but she couldnt recall what reason she selected., Due to problems with communication between electronic health records, medication dispensing cabinets, and the hospital pharmacy that were causing delays in administering medications, the hospital was using workarounds that overrode the safeguards built into the medicine cabinets so staff could access drugs quickly when needed. All rights reserved. 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. Vaught, 36, of, 1. "Yes, we have lost some mojo, the pandemic being one reason," he said. By the definition of reckless,the defendants actions justify the charge.. Public records list Murphey as a 75-year-old resident of Gallatin. 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. The pandemic has only compounded the crisis in the health care sector. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. Are you a nurse? It's vecuronium.". Opens in a new tab or window, Visit us on LinkedIn. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. 286 0 obj
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Opens in a new tab or window, Visit us on TikTok. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. Opens in a new tab or window, Visit us on Facebook. Brett Kelman is the health care reporter for The Tennessean. "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. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. 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.". 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. 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. She died one day later after being taken off of a breathing machine. 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. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. 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 overridingsafeguards at one of the hospitals medicine dispensing cabinets, ex-nurse Radonda Vaught, 35, of Bethpage, had been indicted, grabbed the wrong medication from one of the hospitals electronic prescribing cabinets, Your California Privacy Rights / Privacy Policy. VUMC quickly distanced itself from the incident. 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." The nurse who administered the drug was fired. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! Follow. h222U0Pw/+Q0L)62)IXTb;; `t
<< >> 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. 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. 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 hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. 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 Facebook. /Length 2913 Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt about the Vanderbilt case, the ISMP report, and the CMS report. 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 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. 2023 Institute for Safe Medication Practices. And this has just set us back.". ~sV
Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. 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. You may commit medication mistakes if your diagnosis is erroneous. 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. Is this the med you gave (the patient? Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. 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." Opens in a new tab or window, Share on Twitter. 2. Share on Facebook. Over the next two days, her condition improved. 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 Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. 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. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. 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. Course Hero is not sponsored or endorsed by any college or university. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. 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. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. You couldnt get a bag of fluids for a patient without using an override function.. Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. ANA cautions against accidental medical errors being tried in a court of law. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. 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. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. 5 0 obj Instead, Murphey was left alone as Vaught was called away to the emergency room. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. 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. lv[{Bbb@9\(5(it=,[0_J#1}|,_? Medication management is important for both CMS and the Joint Commission. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. /FitWindow true Murphey went into cardiac arrest and died on Dec. 27, 2017. % "You couldn't get a bag of fluids for a patient without using an override function.". Brett Kelman is the health care reporter for The Tennessean. 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. Vaught, who is out on bail, has declined to comment. Kristina Fiore leads MedPages enterprise & investigative reporting team. Medication errors are the most common type of medical error. 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. At this point, the report states, the medication error was discovered. If you value in-depth reporting about the issues in our community, please support our work by subscribing. 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. "That's the kind of culture that we're trying to improve. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. 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. 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. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* 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. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. All rights reserved. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j 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 intubated and taken to the ICU. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. 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. 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 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 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. Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 No documentation of discussions between Vanderbilt and the family is publicly available. 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. Follow him on Twitter at @brettkelman. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. 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. 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. 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. A second nurse found a baggie that was left over from the medicationgiven to the patient. The state of Tennessee also revoked her nursing license. 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. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. Cheryl Clark has been a medical & science journalist for more than three decades. Sentinel events, serious patient safety incidents, have reached their highest level since reporting of them began. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. 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