vanderbilt nurse medication error cms report

A criminal investigation was also initiated, and Ms. Vaught was indicted in 2019 for reckless homicide (Class D felony) and physical abuse or gross neglect of an impaired 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. Article describing criminal charges filed against a nurse involved in a fatal medication error She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. 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. About one fifth of the hospital's revenue comes from Medicare payments, according to the hospital's recent quarterly report, so the error had the potential to throw the Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. 286 0 obj <>stream 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. She was intubated and taken to the ICU. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. 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. 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. Opens in a new tab or window, Visit us on TikTok. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. xXksF_U[A[#!`+[[@/%'.sO~)yE6G>4I \oD;"+z|S?]r~^sMkNQ:Qi|w zrK-q/S1{U8+m_PHO0bx&l$E.Btn'8,PcGb*`-##w:""#3~HR: 9,J@;FH #mD="N=* (%DH3^Lj6^2 [Z n&iza}Hutd. 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. 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 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. 2023 www.tennessean.com. 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. Follow him on Twitter at @brettkelman. 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. 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. "Yes, we have lost some mojo, the pandemic being one reason," he said. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. 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. 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. An IOM study found that a hospital patient is subject to one medication error per day. Institute for Safe MedicationPractices According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. 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. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. 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 . However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. Since she couldnt find the Versed in the AccuDose system, she overrode the system, typed in VE, and selected the first medication (Vecuronium Bromide) in the list. 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. Sign up for the WSWS Health Care Workers Newsletter! An entirely preventable error results in a horrific death at a major medical institution. Click here to submit a Letter to the Editor, and we may publish it in print. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j "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.". The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. 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? But as part of the correction plan, to save face with the public, Vaught was singled out for blame. A third strategy, he suggested, is for organizations to make sure their institutional culture does not "enable normalization of deviance," by which nurses and other practitioners normalize the process of finding workarounds, such as overriding safety blocks, to get things done. 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. 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. 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. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. 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. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. /PageMode /UseNone The nurse who administered the drug was fired. The patients primary nurse was not available at the time. 1 0 obj "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". 2023 www.tennessean.com. 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. All rights reserved. You may commit medication mistakes if your diagnosis is erroneous. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. She searched "VE" again and the cabinet produced the paralytic vecuronium. On March 25, 2022, a Vanderbilt nurse, RaDonda Vaught, was found guilty of negligent homicide and gross neglect of an impaired adult, after making a Vaught. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. A second nurse found a baggie that was left over from the medicationgiven to the patient. endstream endobj 289 0 obj <>stream As Vaught explained, Overriding was something we did as a part of our practice every day. 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. Murphey had been prescribed Versed, a sedative, but was inadvertently given a deadly dose of vecuronium, a powerful paralytic used to hold patients still during surgery. At this point, the report states, the medication error was discovered. 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. However, 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. 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. h222U0Pw/+Q0L)62)IXTb;; `t %PDF-1.3 << It's vecuronium.". Murphey went into cardiac arrest and died on Dec. 27, 2017. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. Medication management is important for both CMS and the Joint Commission. See who else is going to Nursing & Law Navigating Problematic Nursing Chapter Standards with CMS TJC, and keep up-to-date with conversations about the event. 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 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 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt about the Vanderbilt case, the ISMP report, and the CMS report. He became extremely symptomatic at work and was brought to your emergency department. 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. All rights reserved. It did not occur during an operating room procedure, Cole noted. 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. 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. Opens in a new tab or window, Share on LinkedIn. % Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. 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. Even though the need for the drug for Murphey was not an emergency, no pharmacist reviewed the override and Vaught withdrew the wrong drug from the Pyxis machine. 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. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. 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. 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. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. 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 Follow. "You couldn't get a bag of fluids for a patient without using an override function.". 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. Opens in a new tab or window, Visit us on Facebook. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. 2023 Institute for Safe Medication Practices. She died one day later after being taken off of a breathing machine. You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. Opens in a new tab or window, Visit us on Facebook. against Nurse Vaught. 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. Opens in a new tab or window, Visit us on YouTube. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened.

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