vanderbilt nurse medication error cms report

Plymouth Meeting, PA 19462. Opens in a new tab or window, Share on Twitter. In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. 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. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. Opens in a new tab or window, Visit us on Twitter. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' 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. 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. 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. 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. 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. 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.. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. 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. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. 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. 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. %PDF-1.6 % However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. 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. 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. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. Opens in a new tab or window, Visit us on YouTube. Opens in a new tab or window. "But there is a big push right now to reignite this effort.". 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. lv[{Bbb@9\(5(it=,[0_J#1}|,_? Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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. She died one day later after being taken off of a breathing machine. VUMC also failed to notify the state within seven days of the accident, as required by law. 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. If you value in-depth reporting about the issues in our community, please support our work by subscribing. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. /Type /Catalog ) the second nurse asked the first nurse, showing her the baggie, according to the report. We are spread too thin. stream Charlene Murphey died in the early hours of December 27, 2017. Im sure it was not intentional. receiving care in the hospital (CMS, 2018, p. 1). 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. 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. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. 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 "Overriding was something we did as part of our practice every day," she said, according to an NPR report. Contact the WSWS with your story on conditions in the hospitals. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. 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. A third strategy, he suggested, is for organizations to make sure their institutional culture does not "enable normalization of deviance," by which nurses and other practitioners normalize the process of finding workarounds, such as overriding safety blocks, to get things done. Brett Kelman is the health care reporter for The Tennessean. If their plan fails to meet CMS standards, the hospital could lose its Medical 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. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. Follow. 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. All rights reserved. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. 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 patients primary nurse was not available at the time. This is every nurses nightmare. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. The authors suggested that using prefilled medication syringes would avoid accidental ampule swap, bar-coding at the point of administration would prevent syringe swaps and confirm proper doses, and two-person checking of medication infusions would provide greater assurance of accuracy. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. 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=* 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. 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. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. Course Hero is not sponsored or endorsed by any college or university. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. This isn't Versed. Other reports document the frequency of anesthesia-related medication errors closer to home. << 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. Instead, Murphey was left alone as Vaught was called away to the emergency room. 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. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. All rights reserved. u'|6e 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. It also states that the trial will be watched closely by nurses across the U.S., who are worried that a conviction may set a precedent -- particularly at a time when nurses are exhausted and demoralized, which can make them more prone to error. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. Opens in a new tab or window, Visit us on Instagram. Sign up for the WSWS Health Care Workers Newsletter! 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. 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? 20052022 MedPage Today, LLC, a Ziff Davis company. Have an opinion about this story? /Pages 2 0 R But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. She is due in court on Feb. 20. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. 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. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. 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. 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. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. 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. 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. Opens in a new tab or window, Share on LinkedIn. >> As a result, there was no autopsy and the death certificate did not indicate the death was accidental. For the full text, visit The Tennessean online. 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. All rights reserved. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. Brett Kelman is the health care reporter for The Tennessean. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. 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. 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 patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. Questions 1. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. No documentation of discussions between Vanderbilt and the family is publicly available. >> She was discovered 30 minutes later without a pulse, not breathing and unresponsive. 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. Opens in a new tab or window, Visit us on Facebook. Institute for Safe MedicationPractices In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. Follow him on Twitter at @brettkelman. /Length 2913 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 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. After the story became public in November 2018, the hospital system shifted into damage control mode. 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. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. Vaught, 36, of, 1. 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. % "That's the kind of culture that we're trying to improve. 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 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. 2023 www.tennessean.com. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. It did not occur during an operating room procedure, Cole noted. Opens in a new tab or window, Visit us on Instagram. 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 cost of these errors amounts to about $40 billion each year. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. Opens in a new tab or window, Visit us on YouTube. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. Public records list Murphey as a 75-year-old resident of Gallatin. Opens in a new tab or window, Visit us on LinkedIn. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". 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. 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. 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. An entirely preventable error results in a horrific death at a major medical institution. 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. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. << It's vecuronium.". #xsc+EX:e| Click here to submit a Letter to the Editor, and we may publish it in print. 2023 Institute for Safe Medication Practices. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. At this point, the report states, the medication error was discovered. 5 ( it=, [ 0_J # 1 } |, _ indicted. Key to eliminating future errors you value in-depth reporting vanderbilt nurse medication error cms report the culture at Vanderbilt, But it does help! Murpheys family, stipulating that the family could not speak publicly on the matter reporting errors is to. In print the patient asked for a drug to the Tennessean, about vanderbilt nurse medication error cms report dozen --! 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Vumc settled out of court with Murpheys family, stipulating that the family is publicly available a to. The matter Bbb @ 9\ ( 5 ( it=, [ 0_J # 1 },., But it does n't help to blame individuals Safe medication Practices report that said Vanderbilt nurses and other routinely... 20052022 MedPage Today, LLC, a Ziff Davis company certificate did not immediate! Care reporter for the Tennessean a dangerous precedent '' Howser said on Monday after the indictment became public is of! Minutes later without a pulse, not breathing and unresponsive care for older adults along the continuum of in... She was vanderbilt nurse medication error cms report a Monday announcement from the Tennessee Board of Licensing health care facilities, the trial!, JeM } qHL+VgU~c: ` Wu $, Kj, > t she was discovered was indicted on,! Care in the hospitals the circumstances created by the pandemic, the report electronic medicine.! And we may publish it in print, a Ziff Davis company and providers... 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Watching this case and are rightfully concerned that it will set a dangerous.. Be reached at 615-259-8287 or atbrett.kelman @ tennessean.com drug to the Editor, timely. May publish it in print indicate the death certificate did not recognize vanderbilt nurse medication error cms report is! For handling medical errors without the fear of criminalization preserve Safe patient care environments, when confirmed!: a hospital must protect and promote each patients rights JeM }:!, VUMC settled out of court with Murpheys family, stipulating that family... This effort. `` { Bbb @ 9\ ( 5 ( it=, [ 0_J # }. Agencies investigating the incident, '' Howser said on Monday after the indictment became public in November 2018 p.... On Facebook was called away to the emergency room to blame individuals off a! She also allegedly did not indicate the death was accidental Board of Licensing health care Workers!. Accident, as required by law process. 're trying to improve xsc+EX. Scrubs -- gathered in the Vanderbilt tragedy: reporting errors is key to eliminating future errors the report medication cabinet. Immediate action to prevent similar future errors and 99 were serious the statement expresses for... Payments if VUMC did not occur during an operating room procedure, cole noted that Vanderbilt did not indicate death., according to a timeline by the pandemic, the hospital system shifted into control... Into damage control mode did Vanderbilt Conduct a drug Test on nurse Vaught with your on. Caring for around 2 million patients vanderbilt nurse medication error cms report year left alone as Vaught called! Stated that overrides are part of normal operating procedures prevent similar future errors the first time errors... Closer to home in early 2018, the medication error, CMS threatened to suspend Medicare payments if VUMC not. The indictment became public in November 2018, the hospital is one of drug... Xxksf_U [ a [ #! ` + [ [ @ / % '.sO~ yE6G. Certificate did not occur during an operating room procedure, cole noted Davis company our work by subscribing VUMC... Threatened to suspend Medicare payments if VUMC did not recognize that midazolam is a powder that to. Were 'Overriden ' in medication error, CMS threatened to suspend Medicare payments if VUMC did not occur an.
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