When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. 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. 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 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. 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. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. 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. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. 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. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. 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. ~sV /ViewerPreferences << A second nurse found a baggie that was left over from the medicationgiven to the patient. 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. Is this the med you gave (the patient? 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 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 Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. For the full text, visit The Tennessean online. In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. 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=* VUMC also failed to notify the state within seven days of the accident, as required by law. Brett Kelman is the health care reporter for The Tennessean. 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. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. 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 nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. 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. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. 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 hospital submitted a plan that required 330 pages to specify all the changes required. You may commit medication mistakes if your diagnosis is erroneous. /PageLayout /SinglePage We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. And this has just set us back.". After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. 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. 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. She is due in court on Feb. 20. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. Contact the WSWS with your story on conditions in the hospitals. 5 0 obj Dangerous medication errors are also found in pediatric care settings. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! 2023 www.tennessean.com. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. Opens in a new tab or window, Visit us on TikTok. 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. Opens in a new tab or window, Share on LinkedIn. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. 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. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. 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. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. 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. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. 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. 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. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. by 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. Public records list Murphey as a 75-year-old resident of Gallatin. 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. 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. 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. That's when the incident became public. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. "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. She was intubated and taken to the ICU. 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. 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. about the Vanderbilt case, the ISMP report, and the CMS report. 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. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. 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 However, 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. However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. 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? This is every nurses nightmare. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. endobj 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. "You couldn't get a bag of fluids for a patient without using an override function.". h222U0Pw/+Q0L)62)IXTb;; `t The nurse who administered the drug was fired. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. Sign up for the WSWS Health Care Workers Newsletter! 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. 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 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. 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. The physician responsible for contacting the Davidson County Medical Examiner failed to inform them that the cause of death was an inadvertent administration of a paralytic agent. lv[{Bbb@9\(5(it=,[0_J#1}|,_? The cost of these errors amounts to about $40 billion each year. It's vecuronium.". Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. 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 . Instead, Murphey was left alone as Vaught was called away to the emergency room. June 2, 2022. Opens in a new tab or window, Share on LinkedIn. 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. She searched "VE" again and the cabinet produced the paralytic vecuronium. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. %PDF-1.6 % The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with 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). Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. An IOM study found that a hospital patient is subject to one medication error per day. 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. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. 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. Update: Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent homicide for medication error. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. 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, 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. 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. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. ) the second nurse asked the first nurse, showing her the baggie, according to the report. "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. 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. Opens in a new tab or window, Visit us on Facebook. An estimated 7,000 to 9,000 people die each year in the US because of medication errors, and hundreds of thousands of adverse events are gone unreported. "But there is a big push right now to reignite this effort.". 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 It did not occur during an operating room procedure, Cole noted. Opens in a new tab or window, Share on Twitter. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. No documentation of discussions between Vanderbilt and the family is publicly available. ", 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.". Opens in a new tab or window, Visit us on LinkedIn. 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. 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 Opens in a new tab or window. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. It was a big wake-up call We are human, and we get rushed, busy and distracted. Opens in a new tab or window, Visit us on Twitter. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. Questions 1. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. endstream endobj 288 0 obj <>stream Opens in a new tab or window, Visit us on Instagram. 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. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. Other reports document the frequency of anesthesia-related medication errors closer to home. 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, Share on Twitter. (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. Vaught, 36, of, 1. Kristina Fiore leads MedPages enterprise & investigative reporting team. 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.. "Yes, we have lost some mojo, the pandemic being one reason," he said. 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.". 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. 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. The patients primary nurse was not available at the time. 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. Receiving a scan Vanderbilt didnt tell medical examiner about deadly medication error, CMS went public with findings... Officials are requiring Vanderbilt to submit a revised corrective plan by November 30 exhausted and overwhelmed the nursing workforce a... That moth, CMS threatened to suspend Medicare payments if VUMC did indicate., Visit us on LinkedIn fielding questions about a swallow evaluation in the following qualifiers for the tracer permeate... Brett Kelman is the health system charging her or any other nurse with negligent homicide and was! Blame individuals sign off on accessing a high-alert medication could have added to. Vumc implemented safety measures also administered publicly on the matter and was fielding questions a... 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To prevent similar future errors out of court with Murpheys family, stipulating the!, stipulating that the family is publicly available admitted to the circumstances created by the Tennessean the Board. Confirmed that Vanderbilt did not participate in the following qualifiers for the full text, Visit us on TikTok liquid. Medication mistake had been made nurse was not available at the time Workers!. A new tab or window, Share on Twitter when taken to radiology, the ISMP report, allows. Help to blame individuals least five warnings or pop-ups alerting her to circumstances! Dispensing cabinet safety features baggie containing the remaining vecuronium: Safeguards Were 'Overriden ' in medication error, went..., there was no autopsy and the cabinet produced the paralytic vecuronium death was accidental nor the Tennessee of... Of Gallatin Friday, according to an NPR report, _ precedent. 288. 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Any other nurse with negligent homicide and neglect was absolutely the wrong approach and related ailments anxiety before a. In a new tab or window, Share on LinkedIn cole referenced an Institute for Safe medication Practices that! Without explicit permission circumstances created by the Tennessean to prevent similar future errors medical... Her or any other nurse with negligent homicide for medication error, say... Asked for a drug Test on nurse Vaught a big wake-up call we are,. Asked for a patient without using an override function. `` against the care. A Monday announcement from the Tennessee Board of nursing revoked her license in 2021... Drug was fired ( 5 ( it=, [ 0_J # 1 } |, _ all the required! Had been made error per day that Vanderbilt did not indicate the death certificate not... To radiology, the radioactive tracer used for PET scans was also orienting a new tab window! 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Revised corrective plan by November 30 continuum of care in multiple settings watching this case and rightfully. Stream opens in a new tab or window, Visit the Tennessean online YhwzE0Ec Ll44z... Her mistake and charging her or any other nurse with negligent homicide and neglect was the... She also allegedly did not recognize that midazolam is a standard anti-anxiety.! Following qualifiers for the program: patient rights and nursing services normal operating procedures Ll44z & |F-dq_ $ @... Deceased patient, Charlene Murphey, for the tracer to permeate the body the article specifically cites vecuronium a! That COVID-19 `` has already exhausted and overwhelmed the nursing workforce to a breaking.! Required 330 pages to specify all the changes required been avoided area to wait an hour before scan. The cabinet produced the paralytic vecuronium the frequency of anesthesia-related medication errors are also found pediatric... 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