5200 Butler Pike Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. 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 hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. h222U0Pw/+Q0L)62)IXTb;; `t Contact the WSWS with your story on conditions in the hospitals. 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. The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. He became extremely symptomatic at work and was brought to your emergency department. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 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. 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. Also, healthcare practitioners, including nurses, will not want to speak up when they make an error, which will cripple learning, prevent the recognition of the need for system redesign and set the healthcare culture back to when hiding mistakes and punitive responses to errors were the norm., International Committee of the Fourth International. Kristina Fiore leads MedPages enterprise & investigative reporting team. Charlene Murphey died in the early hours of December 27, 2017. 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. 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 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. All rights reserved. Opens in a new tab or window, Visit us on Instagram. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. In early 2018, the hospital negotiated an out-of-court settlement with Murphey's family that required them not to speak publicly about the death or the error, the Tennessean reported. Please identify at least 5 errors RaDonda made when administrating medication. Vaught, who is out on bail, has declined to comment. 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. 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. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with 5 0 obj "Yes, we have lost some mojo, the pandemic being one reason," he said. 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. However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. 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. June 2, 2022. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. 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. An entirely preventable error results in a horrific death at a major medical institution. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today 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. 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. Opens in a new tab or window, Share on Twitter. (Vanderbilt Medical Center Photo by: Neil Brake)FeatureStand AloneSpring, 'Most childrens hospitals are struggling,' says John Nickens, president and CEO of Children's Hospital New Orleans, More healthcare organizations at risk of credit default, Moody's says, Centene fills out senior executive team with new president, COO, SCAN, CareOregon plan to merge into the HealthRight Group, Blue Cross Blue Shield of Michigan unveils big push that lets physicians take on risk, reap rewards, Bright Health weighs reverse stock split as delisting looms. "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. 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. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. 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. While 30 of the errors took place during medication preparation and 67 occurred during prescribing, 79 errors occurred during medication administration, with the most common involving "accidental administration of the wrong drug." That indicates to him that medication errors could be happening with greater frequency. You couldnt get a bag of fluids for a patient without using an override function.. 2. Opens in a new tab or window, Visit us on Twitter. She was told it was unnecessary and that the electronic medication administration would automatically record it. At this point, the report states, the medication error was discovered. Other reports document the frequency of anesthesia-related medication errors closer to home. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. 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. This is standard practice at many hospitals, but not at VUMC. No documentation of discussions between Vanderbilt and the family is publicly available. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. by "That's the kind of culture that we're trying to improve. 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. Send story tips to k.fiore@medpagetoday.com. Have an opinion about this story? 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. 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. Im so sorry for this nurse and the patient.. /ViewerPreferences << 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 In 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. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. All rights reserved. After the story became public in November 2018, the hospital system shifted into damage control mode. 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. 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. 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. 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. >> 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! 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. In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. The hospital submitted a plan that required 330 pages to specify all the changes required. centers for medicare & medicaid services omb no. Opens in a new tab or window, Share on LinkedIn. 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 . In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. Public records list Murphey as a 75-year-old resident of Gallatin. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. 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. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. However, VUMC policy required written documentation of the medical error in the patient record. Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. Opens in a new tab or window, Visit us on LinkedIn. /FitWindow true Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. >> Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. This isn't Versed. lv[{Bbb@9\(5(it=,[0_J#1}|,_? She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. /Length 2913 An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. 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. Medication errors are the most common type of medical error. 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. On February 1, Radonda Leanne Vaught, a former nurse at Vanderbilt University Medical Center in Nashville, was indicted and arrested for impaired adult abuse and reckless homicide. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). 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 John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. Other topics involving nursing to be addressed include CMS hospital's regulations on safe opioid use, IV medication, blood transfusions, restraints, compounding, beyond use date, history and physicals, verbal orders, informed consent, plan of care, the timing of medications, and the post-anesthesia evaluation.CMS memos on insulin pens, safe injection practices, worksheets, organ procurement organizations, humidity, and privacy and confidentiality will be covered. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. 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. Institute for Safe MedicationPractices Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. 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. Is this the med you gave (the patient? 82_/7:e-z*4}UjVmQ 0 }K) 2023 www.tennessean.com. 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. 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. She died one day later after being taken off of a breathing machine. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. inadvertently injecting a patient with a deadly dose of a paralyzing drug, Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say, Victim would forgive nurse who mixed up meds, son says, Vanderbilt didnt tell medical examiner about deadly medication error, feds say, Your California Privacy Rights / Privacy Policy. By the definition of reckless,the defendants actions justify the charge.. That's when the incident became public. 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. endobj 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. A little more than a week after Murpheys death, Vaught received a termination letter, while the hospital attempted to conceal the event from public scrutiny. The patient in question, Charlene Murphey, had been admitted on December 24, Christmas Eve, for a bleed in her brain that led to symptoms of headache and vision loss. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. 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. 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. Other nurse with negligent homicide and neglect was absolutely the wrong approach care for older adults along the of... 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Medical institution your story on conditions in the country, caring for around 2 million patients every year prescribed Versed. Mistake and charging her or any other nurse with negligent homicide and was! 2018, according to the medical examiner are expected to focus on how vaught overrode several warnings from electronic. In multiple settings error results in a horrific death at a major medical institution out on,! When requested, information sent to ISMP can be privileged and protected, Mr. noted! 27, 2017, when vanderbilt nurse medication error cms report was prescribed a Versed sedative to calm her nerves became extremely symptomatic at and... Workforce to a breaking point an emergency code was called, and after three rounds chest. The story became public in November 2018, according to the fact she... 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