vanderbilt nurse medication error cms report

hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. A second nurse found a baggie that was left over from the medicationgiven to the patient. ", 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.". 2. 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. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today VUMC quickly distanced itself from the incident. 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. 286 0 obj <>stream 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. As Vaught explained, Overriding was something we did as a part of our practice every day. 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. All rights reserved. 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. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. 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. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. 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. 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. Vanderbilt CMS Report Summary (1) (1).docx, 8E1120E8-0BFC-4B6E-A467-38BEA65518E0.jpeg, D3C8E1DD-BA97-4ECC-9D6B-15A66C7A7550.jpeg, Santa Clause Rally Underway - Sizzling Stocks.pdf, 53269012 15841130 14717533 45588921 13725586 16034203 29759789 28628517 59142990, Additional information for Assessments 2 and 3.pdf, Exercises for Task 7 (English Grammar).docx, game attendance for the upcoming season The model should Select one a accurately, Pamantasan ng Lungsod ng Marikina GED161 Hume's Aesthetics Discussion Practice Question.pdf, industria del retail la globalizacin y localizacin de puntos de venta ms, 42 What is an enhancer AThe binding sites for RNA polymerase B The binding sites, DRAFT March 24 2014 22 3 How did you know that the values of the variable really, According to Futurama how much does 1 lb of Dark Matter weigh 1 Quentin, If youre killing a goomba what game are you playing 1 Zelda 2 Call of Duty 3, Senior Management Support Given the resource intensive nature of such projects. 2023 www.tennessean.com. 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. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. Opens in a new tab or window, Share on Twitter. Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. The pandemic has only compounded the crisis in the health care sector. Share on Facebook. A nurse then went to fill this prescription from one of the hospitals electronic prescribing cabinets, which allow staff to search for medicines by name through a computer system. We are spread too thin. 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. 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. lv[{Bbb@9\(5(it=,[0_J#1}|,_? In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. 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. That indicates to him that medication errors could be happening with greater frequency. 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. Send story tips to [email protected]. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). 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 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. 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 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 Instead, Murphey was left alone as Vaught was called away to the emergency room. endobj 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. 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. The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. Follow him on Twitter at @brettkelman. For the full text, visit The Tennessean online. 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. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with %PDF-1.6 % Update: Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent homicide for medication error. Are you a nurse? Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. "Yes, we have lost some mojo, the pandemic being one reason," he said. Cheryl Clark has been a medical & science journalist for more than three decades. 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.. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. Vaught became a registered nurse in February 2015. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. 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. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering 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. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. endstream endobj 288 0 obj <>stream Questions 1. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. 20052022 MedPage Today, LLC, a Ziff Davis company. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. Charlene Murphey died in the early hours of December 27, 2017. 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. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. Opens in a new tab or window, Share on Twitter. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. 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. Opens in a new tab or window, Visit us on Instagram. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. 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. At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. 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. 2023 Institute for Safe Medication Practices. 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. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. Vaught, 36, of, 1. Im so sorry for this nurse and the patient.. "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. 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. 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. >> The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. Michigan nurse speaks on the conditions in hospitals as COVID-19 cases surge, Wisconsin judge temporarily blocks employees from leaving their hospital jobs, Truck drivers protest 110-year sentence for young driver whose brakes failed in 2019 Colorado crash that killed four. The health care executives who have the final say in safety policies at Vanderbilt were found negligent by the Centers for Medicare and Medicaid Services, but they have not been held to account by the prosecutors office. The cost of these errors amounts to about $40 billion each year. 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. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! Dangerous medication errors are also found in pediatric care settings. 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. /PageMode /UseNone After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. Over the next two days, her condition improved. 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. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. Plymouth Meeting, PA 19462. 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. The CMS is threatening to strip Vanderbilt University Medical Center in Nashville, of its ability to care for Medicare patients because a patient died after receiving a large dose of the wrong medication. 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 This isn't Versed. All rights reserved. Opens in a new tab or window, Visit us on YouTube. NEW INFO:Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. 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." Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. Institute for Safe MedicationPractices The nurse who administered the drug was fired. 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. /ViewerPreferences << 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. 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. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. Vaught, who is out on bail, has declined to comment. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. But as part of the correction plan, to save face with the public, Vaught was singled out for blame. 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. 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 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." Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. The state of Tennessee also revoked her nursing license. 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 Have an opinion about this story? (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. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. And this has just set us back.". Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. You may commit medication mistakes if your diagnosis is erroneous. It's vecuronium.". 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. >> Beyond the personal aspects of these events, the prosecution of the nurse is sending waves of resentment among nurses who fear the trial will set a precedent. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. 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. He became extremely symptomatic at work and was brought to your emergency department. Follow him on Twitter at @brettkelman. It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. This is every nurses nightmare. 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. Medication errors are the most common type of medical error. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. ) the second nurse asked the first nurse, showing her the baggie, according to the report. Article describing criminal charges filed against a nurse involved in a fatal medication error "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. At this point, the report states, the medication error was discovered. It did not occur during an operating room procedure, Cole noted. Opens in a new tab or window, Visit us on LinkedIn. 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. 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. 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. Contact the WSWS with your story on conditions in the hospitals. 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=* The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. After the story became public in November 2018, the hospital system shifted into damage control mode. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j 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 LinkedIn. This is standard practice at many hospitals, but not at VUMC. No << 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. 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. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. She died one day later after being taken off of a breathing machine. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt 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 . "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. Medication management is important for both CMS and the Joint Commission. 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. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. An entirely preventable error results in a horrific death at a major medical institution. In 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 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. 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. She searched "VE" again and the cabinet produced the paralytic vecuronium. Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. Despite numerous requests, the corrective action plan has not been made public by the federal government. Is this the med you gave (the patient? 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. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' /FitWindow true The system asked for a reason for the override, but she couldnt recall what reason she selected., Due to problems with communication between electronic health records, medication dispensing cabinets, and the hospital pharmacy that were causing delays in administering medications, the hospital was using workarounds that overrode the safeguards built into the medicine cabinets so staff could access drugs quickly when needed.