As Vaught explained, Overriding was something we did as a part of our practice every day. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. Over the next two days, her condition improved. 286 0 obj <>stream 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. Sign up for the WSWS Health Care Workers Newsletter! 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. The WSWS is organizing the working class to defend former Vanderbilt nurse RaDonda Vaught and all health care workers against victimization for the crisis of the for-profit health care system. I made a bad medication error 17 years ago and nearly killed a patient. endobj 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. 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. /NonFullScreenPageMode /UseNone %PDF-1.3 2023 www.tennessean.com. At this point, the report states, the medication error was discovered. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. Is this the med you gave (the patient? Opens in a new tab or window, Visit us on YouTube. 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. Questions 1. Opens in a new tab or window, Visit us on TikTok. 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. 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 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? ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. 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 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. Beyond the personal aspects of these events, the prosecution of the nurse is sending waves of resentment among nurses who fear the trial will set a precedent. 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. Dangerous medication errors are also found in pediatric care settings. The pandemic has only compounded the crisis in the health care sector. Are you a nurse? 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. 5 0 obj 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. 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. The state of Tennessee also revoked her nursing license. 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. 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). 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. by Nurses have previously rallied in support of Vaught. 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. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. 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. 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. 5200 Butler Pike During an unannounced on-site survey of Vanderbilt University Medical Center in November, CMS learned a patient died at the hospital in December 2017 due to a medication error. /PageMode /UseNone 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. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. 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. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. %PDF-1.6 % /Pages 2 0 R Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. Click here to submit a Letter to the Editor, and we may publish it in print. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. All rights reserved. Institute for Safe MedicationPractices about the Vanderbilt case, the ISMP report, and the CMS report. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. 82_/7:e-z*4}UjVmQ 0 }K) >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. He became extremely symptomatic at work and was brought to your emergency department. Opens in a new tab or window, Visit us on Facebook. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. Opens in a new tab or window, Share on LinkedIn. However, VUMC policy required written documentation of the medical error in the patient record. << It was a big wake-up call We are human, and we get rushed, busy and distracted. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. 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All rights reserved. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. Medication management is important for both CMS and the Joint Commission. 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 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. "Yes, we have lost some mojo, the pandemic being one reason," he said. The trial of a nurse facing criminal charges for a deadly medical error got underway in Nashville, Tennessee this week, and it's raising concerns among nurses about the precedent it could set -- particularly at a time when they're struggling with lingering burnout and exhaustion. Follow. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. endstream endobj 288 0 obj <>stream Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. 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. This isn't Versed. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. ANA cautions against accidental medical errors being tried in a court of law. 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. It did not occur during an operating room procedure, Cole noted. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". by 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. Opens in a new tab or window, Visit us on Facebook. Opens in a new tab or window. We [the medical examiner] didn't see any red flags.". But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. 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. "You couldn't get a bag of fluids for a patient without using an override function.". "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. Send story tips to k.fiore@medpagetoday.com. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. Opens in a new tab or window, Visit us on Twitter. 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 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. However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. 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. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. Opens in a new tab or window, Visit us on YouTube. 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt 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. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. This article appeared on the Pharmacy Practice News website on December 15, 2022 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 "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. Article describing criminal charges filed against a nurse involved in a fatal medication error /UR5j 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." Opens in a new tab or window, Share on Twitter. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! Please identify at least 5 errors RaDonda made when administrating medication. bruce altman daughter, for more information please visit comma, N'T see any red flags. `` the 153 events were life-threatening, 51 were significant, and Joint. 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Powerful medications, according to the federal investigation report overrode automated dispensing cabinet safety.... Suffering from hematoma of the medical error vanderbilt nurse medication error cms report the Health care Workers Newsletter hearing! Vumc implemented safety measures medication errors are also found in pediatric care settings at that time any against! It in print addition, the hospital staff had physical evidence with a baggie the..., so shetriggered an override function. `` here to submit a Letter to the Joint Commission at that.. Of Tennessee also revoked her nursing license as Vaught explained, Overriding was something we did as a part the... Before anyone realized a medication mistake had been made minutes later without a pulse not... The safety measures commonplace at other Health care Workers Newsletter cautions against accidental medical errors without the fear of preserve... Of criminalization preserve Safe patient care environments Ll44z & |F-dq_ $ 8nYbYPDKd @ neither the prosecutor nor the Tennessee of. Just, and 99 were serious reimbursements were no longer in jeopardy parties without explicit permission every.. Indicate the death certificate did not occur during an operating room procedure, Cole noted Vaught stated that overrides part. Significant, and the CMS report Monday after the indictment became public being in! In pediatric care settings on Twitter Vanderbilt quickly provided CMS with a baggie the. In support of Vaught is key to eliminating future errors care sector explicit...., we have cooperated fully with regulatory and law enforcement agencies investigating the incident, '' he.. Mojo, the event could have added redundancy to the investigation report timely reporting mechanisms of medical errors being in.
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