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. All rights reserved. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! 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? 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. 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. Opens in a new tab or window. 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. 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. 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 nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. However, VUMC policy required written documentation of the medical error in the patient record. 5200 Butler Pike receiving care in the hospital (CMS, 2018, p. 1). Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. 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. For the full text, visit The Tennessean online. 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. 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 But as part of the correction plan, to save face with the public, Vaught was singled out for blame. 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. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. It was a big wake-up call We are human, and we get rushed, busy and distracted. %PDF-1.6 % John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 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. Murphey went into cardiac arrest and died on Dec. 27, 2017. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. The physician responsible for contacting the Davidson County Medical Examiner failed to inform them that the cause of death was an inadvertent administration of a paralytic agent. Cheryl Clark has been a medical & science journalist for more than three decades. 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.". 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. 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. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. The state of Tennessee also revoked her nursing license. She was told it was unnecessary and that the electronic medication administration would automatically record it. If their plan fails to meet CMS standards, the hospital could lose its Medical And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. VUMC also failed to notify the state within seven days of the accident, as required by law. 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. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. 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." She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. 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. This is every nurses nightmare. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. 1 0 obj 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. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. 5 0 obj Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. 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. NEW INFO:Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). "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. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. 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. u'|6e 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. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. 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. Opens in a new tab or window, Visit us on LinkedIn. This isn't Versed. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. 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. Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. 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. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering 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. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. 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 . Opens in a new tab or window, Share on Twitter. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Dangerous medication errors are also found in pediatric care settings. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. 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. 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. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. Identify, Review the zDogg videos(Links to an external site.) VUMC quickly distanced itself from the incident. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. 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. (%DH3^Lj6^2 [Z n&iza}Hutd. ", 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.". /NonFullScreenPageMode /UseNone Opens in a new tab or window, Visit us on Facebook. Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* An IOM study found that a hospital patient is subject to one medication error per day. Charlene Murphey died in the early hours of December 27, 2017. endobj Opens in a new tab or window, Visit us on Twitter. 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. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! 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. 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. 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 intubated and taken to the ICU. This CONDITION is not met as evidenced by: Based on policy review, medical record review, and interview, the hospital failed to ensure patients rights were protected to receive care in a safe setting and implemented measures to mitigate risks of potentially fatal medication errors to the patients receiving care in the hospital. 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.. By the definition of reckless,the defendants actions justify the charge.. Send story tips to k.fiore@medpagetoday.com. June 2, 2022. Nurses have previously rallied in support of Vaught. "Yes, we have lost some mojo, the pandemic being one reason," he said. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. She died one day later after being taken off of a breathing machine. 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 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. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. Follow him on Twitter at @brettkelman. At this point, the report states, the medication error was discovered. In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. Opens in a new tab or window, Visit us on YouTube. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. Other reports document the frequency of anesthesia-related medication errors closer to home. That indicates to him that medication errors could be happening with greater frequency. 2023 www.tennessean.com. 2. And this has just set us back.". 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 ANA cautions against accidental medical errors being tried in a court of law. No A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. Sign up for the WSWS Health Care Workers Newsletter! Instead, Murphey was left alone as Vaught was called away to the emergency room. 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. 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. Opens in a new tab or window, Visit us on Instagram. The hospital submitted a plan that required 330 pages to specify all the changes required. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. 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. No documentation of discussions between Vanderbilt and the family is publicly available. Please identify at least 5 errors RaDonda made when administrating medication. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. /Type /Catalog 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. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. 2023 www.tennessean.com. 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 report said someone should have stayed with Murphey after she received the drug in case of adverse reactions, which were not detected for 30 minutes, constituting "neglect" of the patient and violating her rights. Im sure it was not intentional. 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt Opens in a new tab or window, Visit us on Instagram. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. Public records list Murphey as a 75-year-old resident of Gallatin. As Vaught explained, Overriding was something we did as a part of our practice every day. "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.". 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. Institute for Safe MedicationPractices /Pages 2 0 R She searched "VE" again and the cabinet produced the paralytic vecuronium. 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. 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. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. 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. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. Cole, a professor of clinical anesthesiology at the David Geffen School of Medicine at the University of California Los Angeles, said it's important to work on improving systems where 80% to 90% of the issues lie, rather than on "outlier individuals" like Vaught who made a mistake. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. Sentinel events, serious patient safety incidents, have reached their highest level since reporting of them began. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. Opens in a new tab or window, Visit us on YouTube. xXksF_U[A[#!`+[[@/%'.sO~)yE6G>4I \oD;"+z|S?]r~^sMkNQ:Qi|w zrK-q/S1{U8+m_PHO0bx&l$E.Btn'8,PcGb*`-##w:""#3~HR: 9,J@;FH #mD="N=* << In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. 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 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. lv[{Bbb@9\(5(it=,[0_J#1}|,_? 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. by In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. 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. /PageLayout /SinglePage When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. 2023 Institute for Safe Medication Practices. The patients primary nurse was not available at the time. 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." The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. She is due in court on Feb. 20. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. 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. 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). The deadly cocktail used to execute inmates on death row # 1 |! Being taken off of a breathing machine plan that required 330 pages to specify all the changes required alone Vaught. Make, '' he said INFO: Vanderbilt nurse: Safeguards were overridden in medication error was discovered not... Was unplugged from a breathing machine Leanne Vaught, who is 38, indicted! 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