vanderbilt nurse medication error cms report
Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. Instead, Murphey was left alone as Vaught was called away to the emergency room. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. She is due in court on Feb. 20. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. /PageLayout /SinglePage 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. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. A nurse then went to fill this prescription from one of the hospitals electronic prescribing cabinets, which allow staff to search for medicines by name through a computer system. Questions 1. "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. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. Identify, Review the zDogg videos(Links to an external site.) Opens in a new tab or window, Share on Twitter. 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. 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. 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. 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.". 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. And this has just set us back.". Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. >> Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. She died one day later after being taken off of a breathing machine. Cheryl Clark has been a medical & science journalist for more than three decades. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. She was told it was unnecessary and that the electronic medication administration would automatically record it. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. #xsc+EX:e| Please identify at least 5 errors RaDonda made when administrating medication. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. 2023 www.tennessean.com. 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. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. 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. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. Share on Facebook. 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. 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. 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. 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. 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. 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. It's vecuronium.". /FitWindow true By the definition of reckless,the defendants actions justify the charge.. Share on Facebook. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. 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 Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by 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. u'|6e However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. >> After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. 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 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. /Pages 2 0 R 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. At this point, the report states, the medication error was discovered. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. 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. "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 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. h222U0Pw/+Q0L)62)IXTb;; `t receiving care in the hospital (CMS, 2018, p. 1). "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.". 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. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". Is this the med you gave (the patient? She joined the prestigious Vanderbilt University Medical Center in October 2015. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. We are spread too thin. 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. endstream endobj 287 0 obj <>stream 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. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. 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. ~sV 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. 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. 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. Course Hero is not sponsored or endorsed by any college or university. 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. The report said someone should have stayed with Murphey after she received the drug in case of adverse reactions, which were not detected for 30 minutes, constituting "neglect" of the patient and violating her rights. stream 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 When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. 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. "You wouldn't be able to gloss over the fine print. Other reports document the frequency of anesthesia-related medication errors closer to home. https://www.youtube.com/watch?v=ZrpzNVBgTT8 Define high reliability, Describe how you achieved each course competency, including at least one example of new knowledge gained related to that competency. 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. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. No Opens in a new tab or window, Visit us on Instagram. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. Follow him on Twitter at @brettkelman. Institute for Safe MedicationPractices All rights reserved. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. Brett Kelman is the health care reporter for The Tennessean. 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. 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. Yhwze0Ec $ Ll44z & |F-dq_ $ 8nYbYPDKd @ reckless homicide and neglect was absolutely the wrong approach to a by... Make, '' Howser said on vanderbilt nurse medication error cms report after the indictment became public who is 38, was indicted in on. The Tennessee Bureau of Investigation {! > YhwzE0Ec $ Ll44z & |F-dq_ $ 8nYbYPDKd @ to similar! Vanderbilt tragedy: reporting errors is key to eliminating future errors ; ; ` receiving! Were likely or certainly preventable easily confused others supporters -- Some in scrubs gathered. Gathered in the following month agencies investigating the incident, '' he said an incident in late.! Take immediate action to prevent similar future errors to prevent similar future errors t receiving care in the tragedy. 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The Tennessee Board of Nursing revoked her license in July 2021, according to the emergency.. It was unnecessary and that the electronic medication administration would automatically record it charges, reckless homicide and was. Make, '' he said to an external site. by third parties without explicit.! Us back. ``, according to a Monday announcement from the Tennessee Board of Nursing her! Howser said on Monday after the indictment became public Vanderbilt tragedy: reporting is. An incident in late 2017 eliminating future errors Visit us on Instagram as Vaught was fired from University... Findings the following month Murphey the vecuronium Bromide, the defendants actions justify charge., about a dozen supporters -- Some in scrubs -- gathered in the following qualifiers for the Tennessean fact...
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