Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. Opens in a new tab or window, Visit us on LinkedIn. 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. 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. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. Identify, Review the zDogg videos(Links to an external site.) VUMC also failed to notify the state within seven days of the accident, as required by law. 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. 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. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. 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. All rights reserved. It's vecuronium.". 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. Vaught became a registered nurse in February 2015. "But there is a big push right now to reignite this effort.". The most common ones involved opioids or sedative/hypnotics. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. Cheryl Clark has been a medical & science journalist for more than three decades. Institute for Safe MedicationPractices However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. 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. 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. 286 0 obj <>stream Charlene Murphey died in the early hours of December 27, 2017. receiving care in the hospital (CMS, 2018, p. 1). 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. Brett Kelman is the health care reporter for The Tennessean. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. 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.. Despite numerous advances in anesthesia safety over the years, former Tennessee nurse RaDonda Vaught's deadly medication error could have been prevented with a few system-wide fixes that aren't that difficult or costly. 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. 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. 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. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. June 2, 2022. Please identify at least 5 errors RaDonda made when administrating medication. 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. By the definition of reckless,the defendants actions justify the charge.. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. The pandemic has only compounded the crisis in the health care sector. This is standard practice at many hospitals, but not at VUMC. Despite numerous requests, the corrective action plan has not been made public by the federal government. At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. Cheryl Clark, Contributing Writer, MedPage Today 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. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. 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. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. 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). He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Opens in a new tab or window, Visit us on Twitter. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. The hospital submitted a plan that required 330 pages to specify all the changes required. 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. 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. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! In a new advisory, the organization recommends that leaders make changes so mix-ups and missteps like those that killed 75-year-old Vanderbilt University Medical Center patient Charlene Murphey are nearly impossible. She was told it was unnecessary and that the electronic medication administration would automatically record it. The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. Contact the WSWS with your story on conditions in the hospitals. 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. 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. (%DH3^Lj6^2 [Z n&iza}Hutd. 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 by patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). Opens in a new tab or window, Visit us on Facebook. Sign up for the WSWS Health Care Workers Newsletter! 1 0 obj But as part of the correction plan, to save face with the public, Vaught was singled out for blame. No 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. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. 2023 www.tennessean.com. Instead, Murphey was left alone as Vaught was called away to the emergency room. 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. You may commit medication mistakes if your diagnosis is erroneous. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. 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. 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. Medication Error Kills A Vanderbilt Patient | Incident Report 203 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. 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. 2023 Institute for Safe Medication Practices. If you value in-depth reporting about the issues in our community, please support our work by subscribing. endstream endobj 288 0 obj <>stream She was discovered 30 minutes later without a pulse, not breathing and unresponsive. I made a bad medication error 17 years ago and nearly killed a patient. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. 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. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. The system asked for a reason for the override, but she couldnt recall what reason she selected., Due to problems with communication between electronic health records, medication dispensing cabinets, and the hospital pharmacy that were causing delays in administering medications, the hospital was using workarounds that overrode the safeguards built into the medicine cabinets so staff could access drugs quickly when needed. Are you a nurse? 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. That's when the incident became public. 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. VUMC quickly distanced itself from the incident. He became extremely symptomatic at work and was brought to your emergency department. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j endstream endobj 289 0 obj <>stream 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. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! 20052022 MedPage Today, LLC, a Ziff Davis company. Opens in a new tab or window, Visit us on Twitter. 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 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. If their plan fails to meet CMS standards, the hospital could lose its Medical centers for medicare & medicaid services omb no. Click here to submit a Letter to the Editor, and we may publish it in print. 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 .