Im so sorry for this nurse and the patient.. 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. If you value in-depth reporting about the issues in our community, please support our work by subscribing. 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.. lv[{Bbb@9\(5(it=,[0_J#1}|,_? The most common ones involved opioids or sedative/hypnotics. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with 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. u'|6e hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 centers for medicare & medicaid services omb no. 20052022 MedPage Today, LLC, a Ziff Davis company. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. "The error occurred because a staff member had bypassed multiple safety mechanisms that were in place to prevent such errors," said Vanderbilt Spokesman John Howser. "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. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. 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 Medication management is important for both CMS and the Joint Commission. An entirely preventable error results in a horrific death at a major medical institution. The state of Tennessee also revoked her nursing license. 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. This article appeared on the Pharmacy Practice News website on December 15, 2022 He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. She was intubated and taken to the ICU. Follow him on Twitter at @brettkelman. /Length 2913 To minimize medication errors, health practitioners must constantly be vigilant and aware while administering Identify, Review the zDogg videos(Links to an external site.) 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. Cheryl Clark has been a medical & science journalist for more than three decades. The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. 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. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. 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. That's when the incident became public. Vaught, who is out on bail, has declined to comment. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. Opens in a new tab or window, Share on Twitter. 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 Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. 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. All rights reserved. The patients primary nurse was not available at the time. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today For the full text, visit The Tennessean online. Other reports document the frequency of anesthesia-related medication errors closer to home. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. Kristina Fiore leads MedPages enterprise & investigative reporting team. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. Update: Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent homicide for medication error. inadvertently injecting a patient with a deadly dose of a paralyzing drug, Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say, Victim would forgive nurse who mixed up meds, son says, Vanderbilt didnt tell medical examiner about deadly medication error, feds say, Your California Privacy Rights / Privacy Policy. 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. 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. 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. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. 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 submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. 5200 Butler Pike 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. 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. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. 5 0 obj But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. Is this the med you gave (the patient? Plymouth Meeting, PA 19462. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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. Brett Kelman is the health care reporter for The Tennessean. 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. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. (%DH3^Lj6^2 [Z n&iza}Hutd. Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. As Vaught explained, Overriding was something we did as a part of our practice every day. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". Share on Facebook. 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 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. 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. Opens in a new tab or window, Visit us on Facebook. 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. 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. 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 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. Article describing criminal charges filed against a nurse involved in a fatal medication error references an ISMP newsletter article on common mistakes involving neuromuscular blocking agents. Opens in a new tab or window, Share on LinkedIn. 2023 www.tennessean.com. 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. Course Hero is not sponsored or endorsed by any college or university. 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. Click here to submit a Letter to the Editor, and we may publish it in print. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. She searched "VE" again and the cabinet produced the paralytic vecuronium. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. No It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. %PDF-1.3 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). VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. Are you a nurse? 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. 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. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. 1 0 obj 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. ) the second nurse asked the first nurse, showing her the baggie, according to the report. 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. 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. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. CMS stated that Vanderbilt hospital policy was inadequate because it failed to detail any procedure or guidance regarding the manner and frequency of monitoring during and after medications were administered. Charlene was discovered by a transporter. She was found with no pulse and unresponsive in the PET scan patient waiting room. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. Opens in a new tab or window, Visit us on YouTube. No documentation of discussions between Vanderbilt and the family is publicly available. In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. >> Opens in a new tab or window, Visit us on Twitter. 286 0 obj <>stream 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. 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. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. by 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. Medication errors are the most common type of medical error. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. 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