Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. The patients primary nurse was not available at the time. 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. She searched "VE" again and the cabinet produced the paralytic vecuronium. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). Follow him on Twitter at @brettkelman. 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. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. However, further evaluation revealed she had suffered an extensive brain injury from a prolonged lack of oxygen with a very low likelihood of neurological recovery. Later that evening, after speaking with the critical care team, the family agreed that the best course of action was to withdraw all care. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. Opens in a new tab or window, Visit us on Twitter. 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.". Beyond the personal aspects of these events, the prosecution of the nurse is sending waves of resentment among nurses who fear the trial will set a precedent. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. 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 . 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. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. She died one day later after being taken off of a breathing machine. Vecuronium Bromide is a potent paralytic used by an anesthesiologist when they perform intubation procedures, and the drug causes all the muscles to become paralyzed. 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. 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. At this point, the report states, the medication error was discovered. 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. (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. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. 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. However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. #xsc+EX:e| Send story tips to k.fiore@medpagetoday.com. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. June 2, 2022. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. 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. /UR5j << by overridingsafeguards at one of the hospitals medicine dispensing cabinets, ex-nurse Radonda Vaught, 35, of Bethpage, had been indicted, grabbed the wrong medication from one of the hospitals electronic prescribing cabinets, Your California Privacy Rights / Privacy Policy. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. 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. "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. The hospital's physicians also failed to notify state or federal officials of the error or the unexpected death, which they were obligated to do. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. 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. %PDF-1.6 % 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. Vaught was assigned to pick up the medication from the dispensing cabinet and administer it in the radiology department to Murphey before her PET scan. Charlene Murphey died in the early hours of December 27, 2017. If their plan fails to meet CMS standards, the hospital could lose its Medical 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! endstream endobj 289 0 obj <>stream Contact the WSWS with your story on conditions in the hospitals. "You wouldn't be able to gloss over the fine print. 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. 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. receiving care in the hospital (CMS, 2018, p. 1). 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. "But there is a big push right now to reignite this effort.". 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. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. 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. 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. 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. No documentation of discussions between Vanderbilt and the family is publicly available. 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. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. ANA cautions against accidental medical errors being tried in a court of law. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. Over the next two days, her condition improved. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with VUMC quickly distanced itself from the incident. 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. Other reports document the frequency of anesthesia-related medication errors closer to home. Update: Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent homicide for medication error. 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. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. The state of Tennessee also revoked her nursing license. I made a bad medication error 17 years ago and nearly killed a patient. Opens in a new tab or window, Share on LinkedIn. endstream endobj 288 0 obj <>stream Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. 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 During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. lv[{Bbb@9\(5(it=,[0_J#1}|,_? After the story became public in November 2018, the hospital system shifted into damage control mode. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. An IOM study found that a hospital patient is subject to one medication error per day. We are spread too thin. 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. ) the second nurse asked the first nurse, showing her the baggie, according to the report. 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. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. 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. 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. Vaught became a registered nurse in February 2015. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Opens in a new tab or window, Visit us on Instagram. 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. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. 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. 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. Im sure it was not intentional. 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. 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. All rights reserved. The hospital submitted a plan that required 330 pages to specify all the changes required. 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. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. 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. In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. This article appeared on the Pharmacy Practice News website on December 15, 2022 Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. Brett Kelman is the health care reporter for The Tennessean. Describe how you achieved the transferable skill, Critical, module 11 discussion - Reflection Areas for reflection: Describe how you achieved each course competency, including at least one example of new knowledge gained related to that competency Describe, The RaDonda Vaught case RaDonda Vaught, a Tennessee nurse, is the central figure in a criminal case that hascaptivated and horrified medical professionals nationwide. 5200 Butler Pike /Type /Catalog Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. 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. 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. 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. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. 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. stream Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt /PageLayout /SinglePage Medication management is important for both CMS and the Joint Commission. The cost of these errors amounts to about $40 billion each year. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. 1 0 obj Questions 1. Opens in a new tab or window, Visit us on LinkedIn. 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. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. by 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. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. Opens in a new tab or window, Visit us on YouTube. Follow him on Twitter at @brettkelman. This isn't Versed. 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 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. A second nurse found a baggie that was left over from the medicationgiven to the patient. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. Share on Facebook. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering 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. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. 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. In The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. It's vecuronium.". 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 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." Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. VUMC also failed to notify the state within seven days of the accident, as required by law. But as part of the correction plan, to save face with the public, Vaught was singled out for blame. Opens in a new tab or window, Visit us on Facebook. Are you a nurse? 2023 Institute for Safe Medication Practices. 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. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. Kristina Fiore leads MedPages enterprise & investigative reporting team. Nurses have previously rallied in support of Vaught. Identify, Review the zDogg videos(Links to an external site.) You couldnt get a bag of fluids for a patient without using an override function.. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. 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. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. about the Vanderbilt case, the ISMP report, and the CMS report. Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. endobj Despite the requirement that the county medical examiner be notified in the case of unusual or unexpected deaths -- which many patient safety advocates say would detect fixable hospital errors and provide accountability -- hospital officials instead attributed her death to her brain bleed rather than a medication error. 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. "Yes, we have lost some mojo, the pandemic being one reason," he said. 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. And the results of such a mistake can be devastating, according to the institute article, Paralysis starts small, likely with the face or hands, then spreads throughout the body until all muscles are frozen and the patient can no longer breathe.
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