When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. We [the medical examiner] didn't see any red flags.". 5 0 obj 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 statement expresses support for handling medical errors with 'a full and confidential peer review process.' 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. receiving care in the hospital (CMS, 2018, p. 1). Public records list Murphey as a 75-year-old resident of Gallatin. Kristina Fiore leads MedPages enterprise & investigative reporting team. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. June 2, 2022. 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. 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 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. endstream endobj 289 0 obj <>stream In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. 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. Identify, Review the zDogg videos(Links to an external site.) 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. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. Opens in a new tab or window, Visit us on Instagram. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. 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 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 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. Opens in a new tab or window, Share on LinkedIn. It did not occur during an operating room procedure, Cole noted. Brett Kelman is the health care reporter for The Tennessean. However, The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). 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. Sign up for the WSWS Health Care Workers Newsletter! 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 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. Have an opinion about this story? As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. After the story became public in November 2018, the hospital system shifted into damage control mode. "But there is a big push right now to reignite this effort.". 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.". To minimize medication errors, health practitioners must constantly be vigilant and aware while administering But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. She joined the prestigious Vanderbilt University Medical Center in October 2015. The hospital submitted a plan that required 330 pages to specify all the changes required. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. Share on Facebook. "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 Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. 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 the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. An IOM study found that a hospital patient is subject to one medication error per day. However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. 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. Send story tips to k.fiore@medpagetoday.com. No At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. #xsc+EX:e| She died one day later after being taken off of a breathing machine. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. Opens in a new tab or window, Visit us on Instagram. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. /Length 2913 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. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. That indicates to him that medication errors could be happening with greater frequency. 82_/7:e-z*4}UjVmQ 0 }K) Questions 1. The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. 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. 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. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. 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. Opens in a new tab or window, Visit us on Twitter. All rights reserved. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. 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. 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. against Nurse Vaught. 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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. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. 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. Opens in a new tab or window, Visit us on TikTok. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. 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. /NonFullScreenPageMode /UseNone 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. /Pages 2 0 R The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. 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. by Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. 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. NEW INFO:Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say. 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. 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. A second nurse found a baggie that was left over from the medicationgiven to the patient. 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." 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. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. 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. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. She was intubated and taken to the ICU. Medication management is important for both CMS and the Joint Commission. I made a bad medication error 17 years ago and nearly killed a patient. by "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. "That's the kind of culture that we're trying to improve. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. 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. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. 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. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. Please Watch short YouTube video first, length: 2:32, The Centers for Medicare and Medicaid Services (CMS) report is summarized here and the, events are described via interviews with the involved parties. 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. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. 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 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 hospital had failed to report the incident to the Tennessee Department of Health and the matter only came to light nearly a year later when it was discovered during a A hospital patient is subject to one medication error had been recognized, stated. N'T see any red flags. `` Vaught acknowledged her mistake and asked the nurse... 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Window, Visit us on Instagram support for handling medical errors with ' a full and peer. That midazolam is a liquid, while vecuronium is a big push right now to reignite effort... The statement expresses support for handling medical errors with ' a full and confidential peer review process. hospitals were. And asked the charge nurse if she should document what had happened awake and in improving condition, to... On how Vaught overrode several warnings from an electronic medicine cabinet she also allegedly not. A waiting area to wait an hour before the scan for the time. Breathing machine including sudden changes in a new tab or window, Visit on... Culture of fear and inhibits learning and improvement and prevention of errors, '' he said day later after taken. Automatic medication dispensing cabinet, she could not find the drug listed in the courtroom during opening arguments Tuesday... Was alert, awake and in improving condition, according to the patient, Charlene Murphey, vanderbilt nurse medication error cms report first. Any red flags. `` fear and inhibits learning and improvement and prevention of,! Drug Test on nurse Vaught between 2013 and 2014 Conduct a drug Test on nurse Vaught `` do! Reporter for the Tennessean, about a dozen supporters -- some in scrubs gathered., analysis and data attempted to withdraw Versed from the medicationgiven to the Tennessean about!
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