vanderbilt nurse medication error cms report

", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. 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. 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. Other reports document the frequency of anesthesia-related medication errors closer to home. about the Vanderbilt case, the ISMP report, and the CMS report. endobj against Nurse Vaught. She is due in court on Feb. 20. It was a big wake-up call We are human, and we get rushed, busy and distracted. Murphey went into cardiac arrest and died on Dec. 27, 2017. He became extremely symptomatic at work and was brought to your emergency department. Public records list Murphey as a 75-year-old resident of Gallatin. 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. It did not occur during an operating room procedure, Cole noted. 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 errors to the patients. >> WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. 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. 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. She died one day later after being taken off of a breathing machine. 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 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. 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. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. However, further evaluation revealed she had suffered an extensive brain injury from a prolonged lack of oxygen with a very low likelihood of neurological recovery. Later that evening, after speaking with the critical care team, the family agreed that the best course of action was to withdraw all care. 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. Instead, Murphey was left alone as Vaught was called away to the emergency room. /Type /Catalog 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." VUMC quickly distanced itself from the incident. 20052022 MedPage Today, LLC, a Ziff Davis company. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. 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. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. Identify, Review the zDogg videos(Links to an external site.) 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. Since she couldnt find the Versed in the AccuDose system, she overrode the system, typed in VE, and selected the first medication (Vecuronium Bromide) in the list. 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. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. 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. According to an inspection report given to Becker's Hospital Review by CMS, the patient was suffering from hematoma of the brain, headache and other related symptoms Please identify at least 5 errors RaDonda made when administrating medication. All rights reserved. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. ~sV However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. 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. Dangerous medication errors are also found in pediatric care settings. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. >> Vaught, 36, of, 1. stream Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today 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. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. "But there is a big push right now to reignite this effort.". She joined the prestigious Vanderbilt University Medical Center in October 2015. by 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. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. Cheryl Clark has been a medical & science journalist for more than three decades. 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." Click here to submit a Letter to the Editor, and we may publish it in print. 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. 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. Is this the med you gave (the patient? Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. "You wouldn't be able to gloss over the fine print. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. 2. Follow him on Twitter at @brettkelman. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. June 2, 2022. Opens in a new tab or window, Visit us on LinkedIn. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. by 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. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. Have an opinion about this story? At this point, the report states, the medication error was discovered. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. 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. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. 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. The failure of the hospital to mitigate risks associated with medication errors and ensure all patients received care in a safe setting to protect their physical and emotional health and safety placed all patients in a SERIOUS and IMMEDIATE THREAT and placed them in IMMEDIATE JEOPARDY and risk of serious injuries and/or death. >> The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. Opens in a new tab or window, Share on Twitter. Describe how you achieved the transferable skill, Critical, module 11 discussion - Reflection Areas for reflection: Describe how you achieved each course competency, including at least one example of new knowledge gained related to that competency Describe, The RaDonda Vaught case RaDonda Vaught, a Tennessee nurse, is the central figure in a criminal case that hascaptivated and horrified medical professionals nationwide. Opens in a new tab or window, Visit us on Instagram. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. 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 drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. 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. The nurse who administered the drug was fired. 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. Despite numerous requests, the corrective action plan has not been made public by the federal government. 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. << Plymouth Meeting, PA 19462. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. 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. 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. If you value in-depth reporting about the issues in our community, please support our work by subscribing. 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. All rights reserved. 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. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! Charlene Murphey died in the early hours of December 27, 2017. 5200 Butler Pike The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. As Hospital Watchdog noted, Its only natural to wonder if Vanderbilt, an extremely influential political entity, gave a quiet thumbs up behind closed doors to proceed with a prosecution against one of its nurses. We [the medical examiner] didn't see any red flags.". 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=* Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. 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. However, John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. For the full text, visit The Tennessean online. Institute for Safe MedicationPractices Opens in a new tab or window, Visit us on Facebook. 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. "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. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. 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. Even though the need for the drug for Murphey was not an emergency, no pharmacist reviewed the override and Vaught withdrew the wrong drug from the Pyxis machine. Other topics involving nursing to be addressed include CMS hospital's regulations on safe opioid use, IV medication, blood transfusions, restraints, compounding, beyond use date, history and physicals, verbal orders, informed consent, plan of care, the timing of medications, and the post-anesthesia evaluation.CMS memos on insulin pens, safe injection practices, worksheets, organ procurement organizations, humidity, and privacy and confidentiality will be covered. However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. 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 material on this site is for informational purposes only, and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. Opens in a new tab or window, Share on LinkedIn. Questions 1. This isn't Versed. The cost of these errors amounts to about $40 billion each year. The article entitled Paralyzed by Mistakes said that neuromuscular blocking agents like vecuronium have a well-documented history of causing catastrophic injuries or death when used in error. The article goes on to say that the most common error involving these drugs is accidental medication swaps, which are often caused by documents with look-alike names. The article specifically cites vecuronium as a dangerous drug that can be easily confused others. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). 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. That indicates to him that medication errors could be happening with greater frequency. % The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. 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. centers for medicare & medicaid services omb no. She was publicly identified for the first time when she was arrested February 4, 2019 and charged with reckless homicide carrying a possible jail sentence of more than 10 years. A criminal investigation was also initiated, and Ms. Vaught was indicted in 2019 for reckless homicide (Class D felony) and physical abuse or gross neglect of an impaired As Vaught explained, Overriding was something we did as a part of our practice every day. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. #xsc+EX:e| As a result, there was no autopsy and the death certificate did not indicate the death was accidental. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. Brett Kelman is the health care reporter for The Tennessean. "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. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. 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. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. 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. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. /NonFullScreenPageMode /UseNone It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. I made a bad medication error 17 years ago and nearly killed a patient. Opens in a new tab or window. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. Medication management is important for both CMS and the Joint Commission. Im sure it was not intentional. 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. ", 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.". endstream endobj 287 0 obj <>stream Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Opens in a new tab or window, Visit us on Facebook. 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. The most common ones involved opioids or sedative/hypnotics. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. Opens in a new tab or window, Visit us on Twitter. She was told it was unnecessary and that the electronic medication administration would automatically record it. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. 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. /Length 2913 The hospital submitted a plan that required 330 pages to specify all the changes required. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. After the story became public in November 2018, the hospital system shifted into damage control mode. All rights reserved. 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. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' 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. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened.

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