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. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. At this point, the report states, the medication error was discovered. 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. 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 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." Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. 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. 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. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. There was no documentation in this policy detailing any procedure or guidance, regarding the manner and frequency of monitoring patients during and after medications were, Per CMS the Administration of midazolam (Versed) requires an experienced clinician trained in, the use of resuscitative equipment and skilled in airway managementMonitor patients for, early signs of respiratory insufficiency, respiratory depression, hypoventilation, airway, obstruction, or apnea (i.e., via pulse oximetry), which may lead to hypoxia and/or cardiac, At Vanderbilt, There was no documentation in this policy detailing any procedure or guidance, Access to our library of course-specific study resources, Up to 40 questions to ask our expert tutors, Unlimited access to our textbook solutions and explanations. 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. /UR5j He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. The cost of these errors amounts to about $40 billion each year. She was intubated and taken to the ICU. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. 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. /Pages 2 0 R Share on Facebook. Opens in a new tab or window, Share on LinkedIn. 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. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. In A second nurse found a baggie that was left over from the medicationgiven to the patient. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. If convicted, Vaught faces up to 12 years in prison -- though Murphey's family said she would forgive the nurse if she were alive today, according to the Tennessean. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. Vaught became a registered nurse in February 2015. If their plan fails to meet CMS standards, the hospital could lose its Medical Cole feels the issue is critically important, but acknowledges that efforts toward improving patient safety and preventing errors within healthcare systems have died down or lost momentum in recent years, in part because of COVID. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. Course Hero is not sponsored or endorsed by any college or university. She died one day later after being taken off of a breathing machine. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! 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. /PageLayout /SinglePage As Vaught explained, Overriding was something we did as a part of our practice every day. 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 . 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. The physician responsible for contacting the Davidson County Medical Examiner failed to inform them that the cause of death was an inadvertent administration of a paralytic agent. /ViewerPreferences << Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. Institute for Safe MedicationPractices Nurses have previously rallied in support of Vaught. 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. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. Charlene Murphey died in the early hours of December 27, 2017. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. And this has just set us back.". 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. %PDF-1.3 Share on Facebook. 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. /Length 2913 The hospital submitted a plan that required 330 pages to specify all the changes required. If you value in-depth reporting about the issues in our community, please support our work by subscribing. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. He became extremely symptomatic at work and was brought to your emergency department. Public records list Murphey as a 75-year-old resident of Gallatin. The CMS is threatening to strip Vanderbilt University Medical Center in Nashville, of its ability to care for Medicare patients because a patient died after receiving a large dose of the wrong medication. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. receiving care in the hospital (CMS, 2018, p. 1). Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. "Yes, we have lost some mojo, the pandemic being one reason," he said. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. >> This article appeared on the Pharmacy Practice News website on December 15, 2022 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. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. 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). She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. /NonFullScreenPageMode /UseNone 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. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. Have an opinion about this story? CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. 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. << 1 0 obj >> As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. Cheryl Clark has been a medical & science journalist for more than three decades. 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. 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. % 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. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. Opens in a new tab or window, Visit us on TikTok. 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. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. 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. centers for medicare & medicaid services omb no. The state of Tennessee also revoked her nursing license. 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. 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. All rights reserved. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. endstream endobj 289 0 obj <>stream Plymouth Meeting, PA 19462. Brett Kelman is the health care reporter for The Tennessean. The most common ones involved opioids or sedative/hypnotics. March 23, 2022. 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. 2023 www.tennessean.com. 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. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* 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. Opens in a new tab or window, Visit us on YouTube. Opens in a new tab or window. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. 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 Questions 1. 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. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. This CONDITION is not met as evidenced by: Based on policy review, medical record review, and interview, the hospital failed to ensure patients rights were protected to receive care in a safe setting and implemented measures to mitigate risks of potentially fatal medication errors to the patients receiving care in the hospital. 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. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today 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. 5200 Butler Pike Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. It did not occur during an operating room procedure, Cole noted. 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. All rights reserved. After the story became public in November 2018, the hospital system shifted into damage control mode. /FitWindow true Opens in a new tab or window, Visit us on Twitter. 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. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. 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. Contact the WSWS with your story on conditions in the hospitals. 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 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. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. That indicates to him that medication errors could be happening with greater frequency. "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. 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. 82_/7:e-z*4}UjVmQ 0 }K) The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. 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. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. Opens in a new tab or window, Visit us on Instagram. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. Cheryl Clark, Contributing Writer, MedPage Today Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. 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. 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 report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. Opens in a new tab or window, Visit us on Instagram. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. 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 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. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. (%DH3^Lj6^2 [Z n&iza}Hutd. It was a big wake-up call We are human, and we get rushed, busy and distracted.
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