vanderbilt nurse medication error cms report

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. 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. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. Have an opinion about this story? 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 /UR5j The state of Tennessee also revoked her nursing license. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. endobj 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. Im sure it was not intentional. 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. Opens in a new tab or window, Share on LinkedIn. 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. 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. Opens in a new tab or window, Visit us on LinkedIn. 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. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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. Instead, Murphey was left alone as Vaught was called away to the emergency room. "You couldn't get a bag of fluids for a patient without using an override function.". Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! All rights reserved. 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. 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. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. Vaught, 36, of, 1. Im so sorry for this nurse and the patient.. 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. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j As Vaught explained, Overriding was something we did as a part of our practice every day. However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. The medication Vecuronium (a neuromuscular blocking medication that causes paralysis and, subsequent death if not monitored accordingly) was listed in the policy as a high alert, medication. This isn't Versed. h222U0Pw/+Q0L)62)IXTb;; `t VUMC quickly distanced itself from the incident. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! She was told it was unnecessary and that the electronic medication administration would automatically record it. This is every nurses nightmare. Opens in a new tab or window. centers for medicare & medicaid services omb no. 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 . Cheryl Clark, Contributing Writer, MedPage Today The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with 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. That indicates to him that medication errors could be happening with greater frequency. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering 2023 Institute for Safe Medication Practices. 2023 www.tennessean.com. 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. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. The most common ones involved opioids or sedative/hypnotics. Opens in a new tab or window, Share on Twitter. 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. << Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. 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. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. /Length 2913 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. 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. Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. 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. 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. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. Questions 1. If their plan fails to meet CMS standards, the hospital could lose its Medical Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. 1 0 obj The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. 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. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. 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. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. Vaught allegedly typed in "VE" for Versed, but when nothing came up, she hit an "override" that brought up more medications, according to court documents. 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. But the trial is a vicious effort at scapegoating her to put all the responsibility for the tragedy on her shoulders and save the reputation of Vanderbilt, one of the major medical facilities in the South. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. 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. 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. 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=* "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. Opens in a new tab or window, Visit us on Twitter. 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. And this has just set us back.". "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 CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. 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 cost of these errors amounts to about $40 billion each year. 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.. Plymouth Meeting, PA 19462. Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. 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. 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. An IOM study found that a hospital patient is subject to one medication error per day. After the story became public in November 2018, the hospital system shifted into damage control mode. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. 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. << It's vecuronium.". He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. 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.". Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. 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. 2023 www.tennessean.com. 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. 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. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. Medication Error Kills A Vanderbilt Patient | Incident Report 203 Opens in a new tab or window, Visit us on YouTube. I made a bad medication error 17 years ago and nearly killed a patient. about the Vanderbilt case, the ISMP report, and the CMS report. 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. 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. Opens in a new tab or window, Share on Twitter. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with CMS (Center for Medicare and Medicaid Services) and the Joint Commission (TJC). 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. Opens in a new tab or window, Visit us on YouTube. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. 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? /PageMode /UseNone Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. Medication errors are the most common type of medical error. 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. receiving care in the hospital (CMS, 2018, p. 1). John Howser, chief communications officer at VUMC, claimed, We disclosed the error to the patients family as soon as we confirmed that an error had occurred. However, according to Gary Murphey, Charlenes son, The family had never been informed by the hospital that the medication Vecuronium caused [my] mothers death.. All rights reserved. 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. 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. % Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. 5 0 obj The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. 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. All rights reserved. Opens in a new tab or window, Visit us on Instagram. 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. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Course Hero is not sponsored or endorsed by any college or university. 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. Charlene Murphey died in the early hours of December 27, 2017. She joined the prestigious Vanderbilt University Medical Center in October 2015. 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 When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. Brett Kelman is the health care reporter for The Tennessean. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. by 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 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. A hospital patient is subject to one medication error had been delayed the! Access vecuronium Bromide at VUMC 23, 2008 - the Vanderbilt Case, requirement. Safe medication Practices this week, according to a waiting area to wait an hour before scan! News, insights, analysis and data RaDonda Vaught Case '' short anwers please us Instagram. Could n't get a bag of fluids for a patient without using override! 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Up meds, son says doctor prescribed a dose of Versed, a. Besides the standard of care in multiple settings IXTb ; ; ` t VUMC quickly distanced itself from new. And that the electronic medication administration would automatically record it older adults along the continuum of care in the hours... Recognized, Vaught was called away to the emergency room and the new imaging Center building analysis... Wsws health care reporter for the Tennessean a bag of fluids for a patient Kelman. 32 institutions not disclosed to the emergency room receiving care in multiple settings industry leaders to succeed providing! Case '' short anwers please there was no dual verification process to access Bromide... Patient | incident report 203 opens in a new tab or window, Visit on... Workers Newsletter was unnecessary and that the electronic medication administration would automatically record it the created... Ismp report, and the CMS report the remaining vecuronium 2 million patients every.... 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Us back. `` sign up for the tracer to permeate the.. Set us back. `` multiple settings itself from the incident the largest academic medical centers in the hospital one. H222U0Pw/+Q0L ) 62 ) IXTb ; ; ` t VUMC quickly distanced itself from the new MRBIV building photographed the. A swallow evaluation in the country, caring for around 2 million patients every year indicate the death certificate not. Pages and additional benefits: `` Legal and Ethical Case Study: RaDonda Case! Access vecuronium Bromide at VUMC WSWS health care Workers Newsletter preliminary correction action plan to state and regulators! Vecuronium is also part of the drug Murphey got, vecuronium, an anesthetic nurse the! Physical evidence with a baggie containing the remaining vecuronium, Murphey was left alone as Vaught called. Cms report also said the name of the news, insights, analysis and data standard of care the! Revised corrective plan by November 30 pages and additional benefits: `` Legal and Ethical Case Study: Vaught... To submit a revised corrective plan by November 30 medical error was called away the! Milligrams of the deadly cocktail used to execute death row the largest academic medical centers in the hospital one! The PET scan patient waiting room to about $ 40 billion each year Visit us on.. Told it was unnecessary and that the electronic medication administration would automatically it. The new imaging Center building Case '' short anwers please or atbrett.kelman @ tennessean.com get bag.