A second nurse found a baggie that was left over from the medicationgiven to the patient. Murphey went into cardiac arrest and died on Dec. 27, 2017. 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. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. I made a bad medication error 17 years ago and nearly killed a patient. 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. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. >> Opens in a new tab or window, Share on Twitter. "That's the kind of culture that we're trying to improve. Vaught became a registered nurse in February 2015. You couldnt get a bag of fluids for a patient without using an override function.. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. /UR5j 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt 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. All rights reserved. ", 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.". This is every nurses nightmare. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. 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He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. 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). The most common ones involved opioids or sedative/hypnotics. 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 /NonFullScreenPageMode /UseNone 5 0 obj hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j By the definition of reckless,the defendants actions justify the charge.. 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. If their plan fails to meet CMS standards, the hospital could lose its Medical Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. 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. In The NPR report describes Vaught's prosecution as a "rare example of a healthcare worker facing years in prison for a medical error," as such errors are typically handled by licensing boards and civil courts. It's vecuronium.". As a result, there was no autopsy and the death certificate did not indicate the death was accidental. /PageLayout /SinglePage /PageMode /UseNone Nurses have previously rallied in support of Vaught. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. 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. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. 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. /Length 2913 "Overriding was something we did as part of our practice every day," she said, according to an NPR report. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. It was a big wake-up call We are human, and we get rushed, busy and distracted. In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. 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. 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. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. h222U0Pw/+Q0L)62)IXTb;; `t The state of Tennessee also revoked her nursing license. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. Contact the WSWS with your story on conditions in the hospitals. 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. Brett Kelman is the health care reporter for The Tennessean. 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 >> She searched "VE" again and the cabinet produced the paralytic vecuronium. Medication Error Kills A Vanderbilt Patient | Incident Report 203 Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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. 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. 2023 www.tennessean.com. She then typed the first two letters in the drugs name VE into the cabinet and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed. She died one day later after being taken off of a breathing machine. 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. Other topics involving nursing to be addressed include CMS hospital's regulations on safe opioid use, IV medication, blood transfusions, restraints, compounding, beyond use date, history and physicals, verbal orders, informed consent, plan of care, the timing of medications, and the post-anesthesia evaluation.CMS memos on insulin pens, safe injection practices, worksheets, organ procurement organizations, humidity, and privacy and confidentiality will be covered. Other reports document the frequency of anesthesia-related medication errors closer to home. An entirely preventable error results in a horrific death at a major medical institution. 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. 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.. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. 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 After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. 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. For the full text, visit The Tennessean online. 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. 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. %PDF-1.6 % The nurse who administered the drug was fired. Article describing criminal charges filed against a nurse involved in a fatal medication error Sign up for the WSWS Health Care Workers Newsletter! She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. All rights reserved. We are spread too thin. 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. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. "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. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. At Vanderbilt, "the override function allows the nurse to remove a medication from the machine before a pharmacist reviews the order," the CMS report stated. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. 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. 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. Instead, Murphey was left alone as Vaught was called away to the emergency room. ~sV The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. 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. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. Are you a nurse? 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. >> "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. 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. 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. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. 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. 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. Opens in a new tab or window, Visit us on YouTube. Share on Facebook. 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. The patients primary nurse was not available at the time. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. No documentation of discussions between Vanderbilt and the family is publicly available. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. 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 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 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. Despite numerous requests, the corrective action plan has not been made public by the federal government. She was intubated and taken to the ICU. After the story became public in November 2018, the hospital system shifted into damage control mode. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. "Yes, we have lost some mojo, the pandemic being one reason," he said. 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. However, Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. 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. about the Vanderbilt case, the ISMP report, and the CMS report. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. 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. 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 Im so sorry for this nurse and the patient.. 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 . Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. However, VUMC policy required written documentation of the medical error in the patient record. 2023 Institute for Safe Medication Practices. Have an opinion about this story? 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. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. 20052022 MedPage Today, LLC, a Ziff Davis company. 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? During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. All rights reserved. June 2, 2022. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). by 286 0 obj <>stream Medication management is important for both CMS and the Joint Commission. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. 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. Kristina Fiore leads MedPages enterprise & investigative reporting team. But as part of the correction plan, to save face with the public, Vaught was singled out for blame. Nurse: Safeguards Were 'Overriden ' in medication error Sign up for Tennessean! 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2022-11-07