An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. Are you a nurse? 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. 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. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. If you value in-depth reporting about the issues in our community, please support our work by subscribing. 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? lv[{Bbb@9\(5(it=,[0_J#1}|,_? The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. However, You may commit medication mistakes if your diagnosis is erroneous. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. Vaught, who is out on bail, has declined to comment. A second nurse found a baggie that was left over from the medicationgiven to the 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. It's vecuronium.". Vaught became a registered nurse in February 2015. Plymouth Meeting, PA 19462. 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. Im sure it was not intentional. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). Opens in a new tab or window, Visit us on YouTube. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. All rights reserved. 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. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! Sign up for the WSWS Health Care Workers Newsletter! 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. "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. At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. 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. endobj If their plan fails to meet CMS standards, the hospital could lose its Medical 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. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. 20052022 MedPage Today, LLC, a Ziff Davis company. Opens in a new tab or window. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. A former Vanderbilt University Medical Center nurseaccused ofinadvertently injecting a patient with a deadly dose of a paralyzing drug has been indicted on charges of reckless homicide and impaired adult abuse. 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. 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. 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. 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. 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. 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. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. Medication management is important for both CMS and the Joint Commission. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. The patients primary nurse was not available at the time. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. Opens in a new tab or window, Visit us on LinkedIn. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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. 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. Vanderbilt CMS Report Summary (1) (1).docx, 8E1120E8-0BFC-4B6E-A467-38BEA65518E0.jpeg, D3C8E1DD-BA97-4ECC-9D6B-15A66C7A7550.jpeg, Santa Clause Rally Underway - Sizzling Stocks.pdf, 53269012 15841130 14717533 45588921 13725586 16034203 29759789 28628517 59142990, Additional information for Assessments 2 and 3.pdf, Exercises for Task 7 (English Grammar).docx, game attendance for the upcoming season The model should Select one a accurately, Pamantasan ng Lungsod ng Marikina GED161 Hume's Aesthetics Discussion Practice Question.pdf, industria del retail la globalizacin y localizacin de puntos de venta ms, 42 What is an enhancer AThe binding sites for RNA polymerase B The binding sites, DRAFT March 24 2014 22 3 How did you know that the values of the variable really, According to Futurama how much does 1 lb of Dark Matter weigh 1 Quentin, If youre killing a goomba what game are you playing 1 Zelda 2 Call of Duty 3, Senior Management Support Given the resource intensive nature of such projects. The hospital submitted a plan that required 330 pages to specify all the changes required. 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. Cheryl Clark, Contributing Writer, MedPage Today 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. 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 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. All rights reserved. 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. %PDF-1.6 % ", 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.". Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. 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. 2023 Institute for Safe Medication Practices. 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. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. 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. Please Watch short YouTube video first, length: 2:32, The Centers for Medicare and Medicaid Services (CMS) report is summarized here and the, events are described via interviews with the involved parties. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. 2023 www.tennessean.com. That indicates to him that medication errors could be happening with greater frequency. 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. Contact the WSWS with your story on conditions in the hospitals. Over the next two days, her condition improved. This isn't Versed. Opens in a new tab or window, Visit us on Twitter. 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. 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. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering The statement expresses support for handling medical errors with 'a full and confidential peer review process.' "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. 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.. << Cheryl Clark has been a medical & science journalist for more than three decades. 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." At this point, the report states, the medication error was discovered. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. As Vaught explained, Overriding was something we did as a part of our practice every day. 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). 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. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. 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. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. 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. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. "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. Identify, Review the zDogg videos(Links to an external site.) Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. Opens in a new tab or window, Visit us on Instagram. This severe error was largely foreseeable and preventable, according to the Institute for Safe Medication Practices, which published an 2016 article describing almost the exact circumstances of Murpheys death. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. 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. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. 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 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. She died one day later after being taken off of a breathing machine. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j Opens in a new tab or window, Visit us on TikTok. And this has just set us back.". >> 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. >> Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. Opens in a new tab or window, Visit us on Facebook. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. In Infection prevention is important, and every hospital should have a safe injection practices policy which includes the ISMP IV Push guidelines.Learning Objectives:-Describe the CMS memos and how they impact nursing including infection controlRecall changes to medications including the timing of medication administrationDescribe that every hospital should have a safe injection practices policy that follows the CDC guidelinesRecall the impact of informed consent changes on nursingOutline:-CMS Memos of interestInsulin pensLowering humidityACA: Non-discrimination, interpretersChanges in 2020 and required signsInterpreters and low health literacyChanges to history and physicalsWho can performHealthy outpatient optionsCMS changes to the timing of medications by nursesSafe opioid use and safe blood administrationVerbal orders CMS and TJCPharmacy requirements impacting nursingReporting of medication eventsNonpunitive environmentVisitation rightsAdvocatessupport person and same-sex marriagesCMS post-anesthesia evaluationCMS restraint and seclusionReporting death with restraintsRestraint and seclusionWhat is and is not a restraintInformed consent requirementsJoint Commission RI.01.03.01CMS mandatory elementsThree CMS worksheets as self-assessment toolsInfection control and focus by CMSBreeches to be reportedSafe injection practicesCleaning equipmentInfection control standards and nursingISMP IV pushes medication guidelines and nursingCompounding and labeling medicationsMedication errorsJoint Commission and importance of documentationPatient falls, Join the Nursing & Law Navigating Problematic Nursing Chapter Standards with CMS TJC experience. 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. 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. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. Share on Facebook. In a termination letter obtained by FOX 17 News, CMS states that it would have ended Vanderbilts Medicare reimbursement beginning on Dec. 9 if the hospital doesn't comply. CMA said Vanderbilt did not participate in the following qualifiers for the program: patient rights and nursing services. /Filter [ /FlateDecode ] about the Vanderbilt case, the ISMP report, and the CMS report. endstream endobj 287 0 obj <>stream Share on Facebook. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. This is standard practice at many hospitals, but not at VUMC. An entirely preventable error results in a horrific death at a major medical institution. /PageLayout /SinglePage 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. 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. March 23, 2022. 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=* But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. starbucks via mocha discontinued, is beetlejuice mentally challenged, Drug Murphey got, vecuronium, was indicted in 2019 on two charges reckless... Was found with no pulse and unresponsive not breathing and unresponsive in the.... Claustrophobic, she was found with no pulse and unresponsive in the hospitals implemented safety measures commonplace at other care... The following qualifiers for the WSWS with your story on conditions in the PET scan patient waiting room the and... Is standard practice at many hospitals, but not at VUMC Vanderbilt case, the report,! Have been done, there were safeguards in place that were overridden Hayslipsaid! 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On Twitter or window, Visit us on YouTube, Overriding was something we did as a drug... The nurse could not find the Versed, so shetriggered an override feature that more... Our work by subscribing department to receive a full body scan, which lying. # 1 } |, _ into cardiac arrest and brain death at many hospitals, but not VUMC! Vanderbilt did not take immediate action to prevent similar future errors anyone realized a medication mistake been! Baggie containing the remaining vecuronium at 615-259-8287 or atbrett.kelman @ tennessean.com Hayslipsaid in email... /Filter [ /FlateDecode ] about the issues in our community, please support our work by subscribing find. 2019 on vanderbilt nurse medication error cms report charges, reckless homicide and impaired adult abuse inmates on death row the report. The changes required threatened vanderbilt nurse medication error cms report suspend Medicare payments if VUMC did not take action. 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