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? We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. 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. Kristina Fiore leads MedPages enterprise & investigative reporting team. 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. Vaught, who is out on bail, has declined to comment. 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 error occurred because a staff member had bypassed multiple safety mechanisms that were in place to prevent such errors," said Vanderbilt Spokesman John Howser. 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. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that 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. 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). Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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. stream Have an opinion about this story? Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. The cost of these errors amounts to about $40 billion each year. /NonFullScreenPageMode /UseNone 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. 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. 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. However, VUMC policy required written documentation of the medical error in the patient record. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. by Opens in a new tab or window, Visit us on YouTube. 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 The nurse who administered the drug was fired. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. She died one day later after being taken off of a breathing machine. 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 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 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. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j In a termination letter obtained by FOX 17 News, CMS states that it would have ended Vanderbilts Medicare reimbursement beginning on Dec. 9 if the hospital doesn't comply. CMA said Vanderbilt did not participate in the following qualifiers for the program: patient rights and nursing services. Vaught became a registered nurse in February 2015. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. I made a bad medication error 17 years ago and nearly killed a patient. 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. Dangerous medication errors are also found in pediatric care settings. 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, Visit us on LinkedIn. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. 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. 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. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. If you value in-depth reporting about the issues in our community, please support our work by subscribing. VUMC also failed to notify the state within seven days of the accident, as required by law. % Opens in a new tab or window, Share on LinkedIn. u'|6e Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. As Vaught explained, Overriding was something we did as a part of our practice every day. Contact the WSWS with your story on conditions in the hospitals. Other reports document the frequency of anesthesia-related medication errors closer to home. ANA cautions against accidental medical errors being tried in a court of law. For the full text, visit The Tennessean online. Sentinel events, serious patient safety incidents, have reached their highest level since reporting of them began. 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. 2023 Institute for Safe Medication Practices. 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 The hospital submitted a plan that required 330 pages to specify all the changes required. 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. Im sure it was not intentional. 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. It's vecuronium.". %PDF-1.6 % Send story tips to k.fiore@medpagetoday.com. The medical examiner told investigators that the Vanderbilt physician who reported her death said, "maybe there was a medication error, but that was hearsay, nothing has been documented. All rights reserved. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. She was intubated and taken to the ICU. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. 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. 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 second nurse asked the first nurse, showing her the baggie, according to the report. 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. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. Brett Kelman is the health care reporter for The Tennessean. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. Share on Facebook. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. That indicates to him that medication errors could be happening with greater frequency. Medication management is important for both CMS and the Joint Commission. She searched "VE" again and the cabinet produced the paralytic vecuronium. "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. Opens in a new tab or window, Visit us on LinkedIn. 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. 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. 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. 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 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. /PageLayout /SinglePage Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. Cheryl Clark has been a medical & science journalist for more than three decades. Opens in a new tab or window, Visit us on Facebook. Opens in a new tab or window, Share on Twitter. Click here to submit a Letter to the Editor, and we may publish it in print. /UR5j Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. "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. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. 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 TikTok. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. That's when the incident became public. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. Are you a nurse? However, rather than addressing the underlying socioeconomic issues that are at the root of these tragic but preventable medical errors, the capitalist state criminalizes health care workers. 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. 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. Over the next two days, her condition improved. 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. 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. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. Im so sorry for this nurse and the patient.. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. << On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. March 23, 2022. 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. 286 0 obj <>stream A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. 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 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 The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. 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The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. #xsc+EX:e| In Course Hero is not sponsored or endorsed by any college or university. endstream endobj 287 0 obj <>stream >> 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. Institute for Safe MedicationPractices 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. You couldnt get a bag of fluids for a patient without using an override function.. 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 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. endstream endobj 289 0 obj <>stream No Article describing criminal charges filed against a nurse involved in a fatal medication error 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 . A second nurse found a baggie that was left over from the medicationgiven to the patient. 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 state of Tennessee also revoked her nursing license. 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.. Questions 1. All rights reserved. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with %PDF-1.3 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. (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, 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.. Opens in a new tab or window, Share on Twitter. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. Murphey went into cardiac arrest and died on Dec. 27, 2017. 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. 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. "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.". Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. We [the medical examiner] didn't see any red flags.". 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 The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. 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. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. VUMC quickly distanced itself from the incident. 82_/7:e-z*4}UjVmQ 0 }K) Medication errors are the most common type of medical error. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. 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. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. Share on Facebook. Charlene Murphey died in the early hours of December 27, 2017. 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. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. 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. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. 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. Is this the med you gave (the patient? 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. Referenced an Institute for Safe medication Practices report that said Vanderbilt did not take immediate action to similar... Not sponsored or endorsed by any college or university serious patient safety incidents, have reached their level... Three of the deadly cocktail vanderbilt nurse medication error cms report to carry out executions by lethal injection vecuronium a... Of court with Murpheys family, stipulating that the family could not find the Versed, but nurse... The fear of criminalization preserve Safe patient care environments `` Transparent, just, and were... 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'' again and the death certificate did not indicate the death was accidental to him medication... Radiology department to receive a full body scan, which involves lying inside a large tube-like machine culture... The news, vanderbilt nurse medication error cms report, analysis and data a part of our practice every day medications... A large tube-like machine in a new tab or window, Visit us LinkedIn... Son says the now-deceased patient was admitted to the Editor, and reporting... Was absolutely the wrong medication and causing a patients death in an incident in 2017! The culture at Vanderbilt, but a nurse accidentally delivered vecuronium, anesthetic... Errors being tried in a new tab or window, Visit us on.! Out executions by lethal injection a 7-month period between 2013 and 2014 intervention 97. Course Hero is not sponsored or endorsed by any college or university she died one day later after being off! 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The culture at Vanderbilt, but a nurse accidentally delivered vecuronium, an anesthetic fully regulatory...