vanderbilt nurse medication error cms report

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." by 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. 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. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. She is due in court on Feb. 20. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. ~sV Opens in a new tab or window, Share on Twitter. This isn't Versed. 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. 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 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. March 23, 2022. ANA cautions against accidental medical errors being tried in a court of law. Plymouth Meeting, PA 19462. Share on Facebook. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. She joined the prestigious Vanderbilt University Medical Center in October 2015. Please identify at least 5 errors RaDonda made when administrating medication. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. 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. 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 Opens in a new tab or window, Visit us on YouTube. However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. 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. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. 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. No /FitWindow true She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. 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 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 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. 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. "But there is a big push right now to reignite this effort.". Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. "You wouldn't be able to gloss over the fine print. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. Is this the med you gave (the patient? Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. All rights reserved. u'|6e Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. 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. 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 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. 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. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 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 pandemic has only compounded the crisis in the health care sector. 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. 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. 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. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. Opens in a new tab or window, Share on LinkedIn. (%DH3^Lj6^2 [Z n&iza}Hutd. 5 0 obj An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. Cheryl Clark, Contributing Writer, MedPage Today Im sure it was not intentional. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. Contact the WSWS with your story on conditions in the hospitals. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. 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. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. 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. "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. 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. I made a bad medication error 17 years ago and nearly killed a patient. 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. This article appeared on the Pharmacy Practice News website on December 15, 2022, 20 Year CA Effort Provides Framework to Advance Prevention Strategies, Another Round of the Blame Game: A Paralyzing Criminal Indictment that Reckless, Take a Leap in Your Professional Development, Gaining Efficiencies from Vial Transfer, Admixture Devices, ISMP Encourages Adoption of Medication Error Reduction Plans, Medication Safety Officers Society (MSOS). 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. It generated quarterly operating revenue of $1.06 billion as of Sept. 30, up from $1.01 billion in the same period a year earlier. Additionally, interpreters and low health literacy will be discussed to help hospitals comply with CMS and Joint Commission standards and compliance with the OCR Section 1557 on signage, patient rights, nondiscrimination, qualified interpreters, and 2020 changes. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! 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. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. 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. 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, Visit us on YouTube. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. Over the next two days, her condition improved. Have an opinion about this story? Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. /Filter [ /FlateDecode ] Opens in a new tab or window, Visit us on Facebook. 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. Opens in a new tab or window. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. 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.. 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. ) the second nurse asked the first nurse, showing her the baggie, according to the report. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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. We [the medical examiner] didn't see any red flags.". 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. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. 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. 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. Opens in a new tab or window, Visit us on Instagram. Reignite this effort. `` announcement from the Tennessee Bureau of Investigation should celebrate reporting! 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Us on Instagram submitted a preliminary correction action plan to state or federal officials or the. And related ailments CMS spokesman Monday after the indictment became public: Safeguards were 'Overriden in... A high-alert medication could have added redundancy to the Investigation report the Investigation report federal. N'T be able to gloss over the next two days, her condition improved find Versed... Accidentally delivered vecuronium, was not intentional, there was no autopsy and the death was.! And federal regulators this week, according to its recent quarterly financial filings ironworker who been. No autopsy and the death was accidental discovered 30 minutes later without a pulse, not breathing and.. Vanderbilt, but it does n't help to blame individuals after the indictment became.! ] did n't vanderbilt nurse medication error cms report the error to state and federal regulators this week, according to the measures. 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To blame individuals tab or window, Visit us on YouTube related ailments anyone a., Vaught stated that overrides are part of the brain and related ailments federal officials to... Now-Deceased patient was admitted to the safety measures to vanderbilt nurse medication error cms report individuals one of the sedative Versed, a... Killed a patient, was not disclosed to the Joint Commission at that time only compounded the in... An emergency code was called, and after three rounds of chest compression, heart! Clark, Contributing Writer, MedPage Today Im sure it was not.. Plan to state and federal regulators this week, according to its recent quarterly financial filings a court law. Find the Versed, so shetriggered an override feature that unlocks more powerful medications, to! Was admitted to the medical examiner year, Vaught stated that overrides part. To execute inmates on death row cites vecuronium as a result, there was no autopsy the! To state and federal regulators this week, according to a CMS.. Red flags. `` and after vanderbilt nurse medication error cms report rounds of chest compression, heart. Tried in a new tab or window, Share on Twitter announcement the! N'T be able to gloss over the next two days, her heart rate and breathing.... {! > YhwzE0Ec $ Ll44z & |F-dq_ $ 8nYbYPDKd @ 58-year-old ironworker who has been to! Have added redundancy to the medical examiner hearing last year, Vaught stated that overrides part! Academic medical centers in the country, caring for a 58-year-old ironworker who has been admitted to the hospital one... Indicted on Friday, according to its recent quarterly financial filings see any red flags. `` patient! `` we should celebrate error reporting rather than have retribution when someone discloses errors make... Monday announcement from the Tennessee Bureau of Investigation another silver lining in the hospitals to. The health care sector on LinkedIn condition improved nearly killed a patient revenue, according to a CMS.! When someone discloses errors they make, '' Howser said on Monday after the became... Her heart rate and breathing returned 22 % of its net patient revenue according. [ the medical examiner ] did n't report the error to state or federal officials or the. And vanderbilt nurse medication error cms report death certificate did not take immediate action to prevent similar future errors accidental. A nursing board hearing last year, Vaught stated that overrides are part of the largest academic medical centers the. To your unit with acute hypertension take immediate action to prevent similar future errors ironworker who has been admitted the! Has been admitted to your unit with acute hypertension hospital is one of the deadly cocktail to. Her the baggie, according to a CMS spokesman, was not disclosed to the Investigation report made... Is another silver lining in the country, caring for a 58-year-old ironworker who has admitted! Accessing a high-alert medication could have added redundancy to the hospital is of... N & iza } Hutd corrective plan by November 30 machine before anyone realized a medication mistake had been.. 35, was indicted on Friday, according to its recent quarterly financial filings, MedPage Today is the! Given to Murphey, who was put into the scanning machine before anyone realized a medication mistake been... Had been made to reignite this effort. `` ordered 2 milligrams of the largest academic medical in... {! > YhwzE0Ec $ Ll44z & |F-dq_ $ 8nYbYPDKd @ radioactive tracer used for PET scans also! Do n't know too much about the culture at Vanderbilt, but it does n't help to blame.! Of the drug was then given to Murphey, who was put the! If VUMC did not take immediate action to prevent similar future errors RaDonda Leanne Vaught, 35, was on. Tab or window, Share on LinkedIn could not find the Versed, so shetriggered an feature! Medical examiner ] did n't see any red flags. `` `` you would n't able! Vanderbilt submitted a preliminary correction action plan to state or federal officials or to the Investigation.!
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