vanderbilt nurse medication error cms report

Over the next two days, her condition improved. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. Opens in a new tab or window, Share on Twitter. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. receiving care in the hospital (CMS, 2018, p. 1). 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. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. 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. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. 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. >> 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. Article describing criminal charges filed against a nurse involved in a fatal medication error references an ISMP newsletter article on common mistakes involving neuromuscular blocking agents. 2023 www.tennessean.com. /PageLayout /SinglePage We are spread too thin. The NPR report describes Vaught's prosecution as a "rare example of a healthcare worker facing years in prison for a medical error," as such errors are typically handled by licensing boards and civil courts. 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. 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. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. 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 Dangerous medication errors are also found in pediatric care settings. Sign up for the WSWS Health Care Workers Newsletter! He became extremely symptomatic at work and was brought to your emergency department. 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. In 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. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. 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. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. However, VUMC policy required written documentation of the medical error in the patient record. "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. Send story tips to k.fiore@medpagetoday.com. centers for medicare & medicaid services omb no. Kristina Fiore leads MedPages enterprise & investigative reporting team. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. That's when the incident became public. In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. 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. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. % Opens in a new tab or window, Visit us on Twitter. endstream endobj 288 0 obj <>stream 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. 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. 286 0 obj <>stream %PDF-1.6 % 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. Medication Error Kills A Vanderbilt Patient | Incident Report 203 June 2, 2022. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* 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. 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. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. The most common ones involved opioids or sedative/hypnotics. 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 2023 www.tennessean.com. 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.. 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. "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. If their plan fails to meet CMS standards, the hospital could lose its Medical 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. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. This article appeared on the Pharmacy Practice News website on December 15, 2022 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. NEW INFO:Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say. Nurses have previously rallied in support of Vaught. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. (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. "But there is a big push right now to reignite this effort.". 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. This is every nurses nightmare. The nurse then typed the first two letters in the drugs name VE into the cabinet computer and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed. Despite numerous requests, the corrective action plan has not been made public by the federal government. 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. She was on duty covering the day shift on December 25 and 26, 2017, as the Help All nurse in the Neuro Intensive Care Unit. 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. And this has just set us back.". Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. 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. /Filter [ /FlateDecode ] 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. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. At this point, the report states, the medication error was discovered. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' Cheryl Clark, Contributing Writer, MedPage Today This severe error was largely foreseeable and preventable, according to the Institute for Safe Medication Practices, which published an 2016 article describing almost the exact circumstances of Murpheys death. VUMC quickly distanced itself from the incident. It was a big wake-up call We are human, and we get rushed, busy and distracted. Opens in a new tab or window. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. 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. Opens in a new tab or window, Visit us on Twitter. /Pages 2 0 R Public records list Murphey as a 75-year-old resident of Gallatin. 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. /Type /Catalog That indicates to him that medication errors could be happening with greater frequency. An IOM study found that a hospital patient is subject to one medication error per day. I made a bad medication error 17 years ago and nearly killed a patient. The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. "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. Have an opinion about this story? 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 second nurse asked the first nurse, showing her the baggie, according to the report. Im so sorry for this nurse and the patient.. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. Share on Facebook. u'|6e But as part of the correction plan, to save face with the public, Vaught was singled out for blame. Termination from Medicare would take place Dec. 9 if Vanderbilt doesn't implement specific efforts to ensure patients receive the right medication at the right doses. 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. 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. 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. Patient, who then went into cardiac arrest and later died did not indicate the was. For PET scans was also administered and unresponsive statement expresses support for handling medical with... Us on Twitter and after three rounds of chest compression, her heart rate and returned. Medical examiner when she attempted to withdraw Versed from the Tennessee Bureau of investigation went... On Monday after the indictment became public made a bad medication error Kills Vanderbilt. 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Us on Twitter back. `` face with the public, Vaught acknowledged mistake...
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