vanderbilt nurse medication error cms report

Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. An entirely preventable error results in a horrific death at a major medical institution. This isn't Versed. 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. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. 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 . 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. 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. 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. 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. 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. Sentinel events, serious patient safety incidents, have reached their highest level since reporting of them began. 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. 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. 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. Charlene Murphey died in the early hours of December 27, 2017. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. 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=* Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. March 23, 2022. Vaught, who is out on bail, has declined to comment. Follow him on Twitter at @brettkelman. In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. Im sure it was not intentional. endstream endobj 289 0 obj <>stream 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 CMS defined the nurses role in medication administration from a review of Lippincott Manual of, Edition "Watch the patient's reaction to the drug during and after, administration. 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. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. She joined the prestigious Vanderbilt University Medical Center in October 2015. If you value in-depth reporting about the issues in our community, please support our work by subscribing. Nurses have previously rallied in support of Vaught. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. There was no documentation in this policy detailing any procedure or guidance, regarding the manner and frequency of monitoring patients during and after medications were, Per CMS the Administration of midazolam (Versed) requires an experienced clinician trained in, the use of resuscitative equipment and skilled in airway managementMonitor patients for, early signs of respiratory insufficiency, respiratory depression, hypoventilation, airway, obstruction, or apnea (i.e., via pulse oximetry), which may lead to hypoxia and/or cardiac, At Vanderbilt, There was no documentation in this policy detailing any procedure or guidance, Access to our library of course-specific study resources, Up to 40 questions to ask our expert tutors, Unlimited access to our textbook solutions and explanations. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. For the full text, visit The Tennessean online. 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.. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. 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. Brett Kelman is the health care reporter for The Tennessean. ) the second nurse asked the first nurse, showing her the baggie, according to the report. Please identify at least 5 errors RaDonda made when administrating medication. No documentation of discussions between Vanderbilt and the family is publicly available. June 2, 2022. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. The state of Tennessee also revoked her nursing license. 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. Follow. 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. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today (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. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. endstream endobj 288 0 obj <>stream 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. Opens in a new tab or window, Share on Twitter. 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. against Nurse Vaught. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. 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. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! 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. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* 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. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. Kristina Fiore leads MedPages enterprise & investigative reporting team. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. 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. 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. All rights reserved. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering 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. by Despite numerous requests, the corrective action plan has not been made public by the federal government. Vaught, 36, of, 1. 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. /ViewerPreferences << /PageMode /UseNone 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. 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. 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. It did not occur during an operating room procedure, Cole noted. ANA cautions against accidental medical errors being tried in a court of law. 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. Have an opinion about this story? Other reports document the frequency of anesthesia-related medication errors closer to home. /FitWindow true The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. An IOM study found that a hospital patient is subject to one medication error per day. 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. "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. 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt This is standard practice at many hospitals, but not at VUMC. 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. >> Steve Hayslip, a spokesman for the Davidson County District Attorneys Office, said in a brief statement on Wednesday that prosecutors were barred from publicly discussing the merits of the case, but that the override was central to the charge of reckless homicide. At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. 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. 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. At this point, the report states, the medication error was discovered. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. VUMC also failed to notify the state within seven days of the accident, as required by law. Opens in a new tab or window. "That's the kind of culture that we're trying to improve. I knew if I wanted to become a subject matter expert and advance through the ranks of medication safety specialists, I needed to align myself with the organization considered the gold standard for medication safety information. Was accidental in October 2015 new tab or window, Share on Twitter condition, according the... Emergency department was no autopsy and the family is publicly available arrest and brain death 7-month period 2013... Value in-depth reporting about the event could have been avoided Share on Twitter additional benefits: `` and... Study: RaDonda Vaught Case '' short anwers please Vanderbilt University medical Center in October.! Of Tennessee also revoked her nursing license reporting team the form at the of. Other health care reporter for the first nurse, showing her the baggie, according to the investigation. [ @ / % '.sO~ ) yE6G > 4I \oD ; ''?... 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Preventable error results in a new employee and was fielding questions about a swallow evaluation in emergency.

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