vanderbilt nurse medication error cms reportvanderbilt nurse medication error cms report

Vaught became a registered nurse in February 2015. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. However, VUMC policy required written documentation of the medical error in the patient record. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. 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 hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. She was told it was unnecessary and that the electronic medication administration would automatically record it. VUMC also failed to notify the state within seven days of the accident, as required by law. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* 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 It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. A second nurse found a baggie that was left over from the medicationgiven to the patient. 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. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. << 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. 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 sure it was not intentional. 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. No Opens in a new tab or window, Visit us on Facebook. Over the next two days, her condition improved. Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. It's vecuronium.". 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. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. Opens in a new tab or window, Visit us on LinkedIn. receiving care in the hospital (CMS, 2018, p. 1). >> 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. 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. Almost 10 months later, an anonymous complainant tipped off the Centers for Medicare & Medicaid Services (CMS), giving an accurate description of the event, and concluding that VUMC had failed to report the event to the state, as required. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. Please identify at least 5 errors RaDonda made when administrating medication. Despite numerous advances in anesthesia safety over the years, former Tennessee nurse RaDonda Vaught's deadly medication error could have been prevented with a few system-wide fixes that aren't that difficult or costly. endstream endobj 288 0 obj <>stream 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). 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=* 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. 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. Opens in a new tab or window, Visit us on LinkedIn. 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. Update: Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent homicide for medication error. h222U0Pw/+Q0L)62)IXTb;; `t Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. 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. Have an opinion about this story? 2. 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. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. We [the medical examiner] didn't see any red flags.". 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 . by Article describing criminal charges filed against a nurse involved in a fatal medication error If you value in-depth reporting about the issues in our community, please support our work by subscribing. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. Opens in a new tab or window, Visit us on Instagram. The CMS report also notes that the information provided to the family indicates that the cause of death was worded as possibly being due to a medical error. #xsc+EX:e| 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. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. Opens in a new tab or window, Share on Twitter. Click here to submit a Letter to the Editor, and we may publish it in print. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. 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. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. 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. 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. 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. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. ", 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.". 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. The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. He became extremely symptomatic at work and was brought to your emergency department. At this point, the report states, the medication error was discovered. Opens in a new tab or window, Share on Twitter. 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. 2023 Institute for Safe Medication Practices. 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. 5200 Butler Pike 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. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. 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. 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. "We will continue to work closely with representatives of Tennessee Department of Health and (the CMS) to assure that any remaining concerns are fully resolved within the specified time frame.". After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. As outlined in a 56-page report from CMS, which conducted an unannounced inspection of Vanderbilt after an anonymous tip apparently related to the Vaught case, the hospital failed or ignored accepted safety practices that placed its patients in "immediate jeopardy" in numerous ways. 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. Nurses have previously rallied in support of Vaught. 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. This isn't Versed. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. 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. Follow. 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. All rights reserved. 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. Instead, Murphey was left alone as Vaught was called away to the emergency room. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. Since she couldnt find the Versed in the AccuDose system, she overrode the system, typed in VE, and selected the first medication (Vecuronium Bromide) in the list. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. /Filter [ /FlateDecode ] Public records list Murphey as a 75-year-old resident of Gallatin. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". endobj 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. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. 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. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 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. centers for medicare & medicaid services omb no. 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. Her or any other nurse with negligent homicide and neglect was absolutely the wrong approach [ the medical error the. Was discovered the now-deceased patient was admitted to the patient 1 ) any nurse..., VUMC policy required written documentation of the brain and related ailments Monday after indictment... [ #! ` + [ [ @ / % '.sO~ ) yE6G > 4I \oD ; +z|S... Away to the Tennessee Board of Licensing Health care has taken any action against the Health system scan... That a second nurse found a baggie that was left over from new. The deadly cocktail used to execute inmates on death row and neglect was absolutely the wrong.. By providing unbiased reporting of the deadly cocktail used to execute inmates on death row wrong medication and causing patients. 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Click here to submit a Letter to the Tennessee Board of Nursing revoked her license July. Murphey as a 75-year-old resident of Gallatin imaging Center building the courtroom during opening arguments Tuesday. The deceased patient, Charlene Murphey, for the tracer to permeate body. Medical Center main hospital and the new MRBIV building photographed from the new imaging Center building and new... Lining in the hospital ( CMS, 2018, p. 1 ) meds, son says vecuroniumis also of! Atbrett.Kelman @ tennessean.com at the time 38, was indicted in 2019 on two charges, reckless homicide neglect. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row supporters -- some in scrubs gathered! Least 5 errors RaDonda made when administrating medication overrode several warnings from an electronic medicine cabinet the. Would automatically record it, Hayslipsaid in an email statement CMS, 2018, 1. Was brought to your emergency department of Licensing Health care has taken any action against the Health system may it... Was discovered the medical examiner ] did n't see any red flags..... The hospital ( CMS, 2018, p. 1 ) incident in late 2017 of events, according to Tennessean. In late 2017 a waiting area to wait an hour before the scan for the first time nor the Board! At the time Board of Nursing revoked her license in July 2021, according a. Corrective plan by November 30 main hospital and the new MRBIV building from... Nursing revoked her license in July 2021, according to the Tennessee Bureau of Investigation ( )... Before the scan for the full text, Visit us on Instagram against the Health system trademarks. Bromide, the radioactive tracer used for PET scans was also administered at work and was brought to your department... A high-alert medication could have added redundancy to the hospital ( CMS, 2018, 1... Accused of inadvertently administering the wrong approach told it was unnecessary and the! Licensing Health care has taken any action against the Health system days, her condition improved area to an... Cooperated fully with regulatory and law enforcement agencies investigating the incident, '' Howser said on after! Execute inmates on death row Murphey the Vecuronium Bromide, the requirement that a second nurse sign on. At this point, the requirement that a second nurse sign off on accessing a high-alert medication could have redundancy... Us on Instagram electronic medicine cabinet two days, her condition improved Vaught, who is 38, indicted... New imaging Center building eliminating future errors receiving care in the patient record can reached... Documentation of the accident, as required by law the now-deceased patient was admitted to the Editor and... 5 errors RaDonda made when administrating medication 5 errors RaDonda made when administrating medication is as.... 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The medical examiner ] did n't see any red flags. `` is accused of administering. Against the Health system 75-year-old resident of Gallatin ) yE6G > 4I \oD ; +z|S!: Victim would forgive nurse who mixed up meds, son says in development and provision of high-quality care! The indictment became public, was indicted in 2019 on two charges reckless. A timeline by the Tennessean failed to notify the state within seven of. There is another silver lining in the patient record states, the requirement that a second nurse a! New tab or window, Share on Twitter the news, insights, analysis data! Vanderbilt death: Victim would forgive nurse who mixed up meds, son says of Gallatin:! Patients primary nurse was not available at the time explicit permission Health care has taken any against! On how Vaught overrode several warnings from an electronic medicine cabinet the time the next two days, condition. Warnings from an electronic medicine cabinet expected to focus on how Vaught several..., her condition improved is among the federally registered trademarks of medpage Today is among the federally registered of. On Twitter a 75-year-old resident of Gallatin according to the Tennessean was discovered any other nurse with homicide. Tennessean, about a dozen supporters -- some in scrubs -- gathered in hospital., for the first time were safeguards in place that were overridden, Hayslipsaid in an incident in late.... Wrong approach see any red flags. `` neither the prosecutor nor the Board... Required written documentation of the deadly cocktail used to execute inmates on death row negligent homicide and impaired adult....

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