When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. 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? Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. 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. An estimated 7,000 to 9,000 people die each year in the US because of medication errors, and hundreds of thousands of adverse events are gone unreported. March 23, 2022. The patient was left alone to be scanned for as long as 30 minutes, according to the investigation report, before someone realized the patient was not breathing and medical staff began CPR. 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. 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 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. 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. 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. 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. 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. 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 prescribing cabinets, which allow staff to search for medicines by name through a computer system. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. 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. Other reports document the frequency of anesthesia-related medication errors closer to home. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. Examples of other changes the foundation seeks at all acute care facilities include: Cole noted that medication-related adverse events in anesthesia still occur at unacceptably high rates. 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. 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. Charlene Murphey died in the early hours of December 27, 2017. Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. lv[{Bbb@9\(5(it=,[0_J#1}|,_? Opens in a new tab or window, Visit us on Twitter. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. Despite numerous requests, the corrective action plan has not been made public by the federal government. u'|6e 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. She joined the prestigious Vanderbilt University Medical Center in October 2015. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. Opens in a new tab or window, Visit us on LinkedIn. However, We [the medical examiner] didn't see any red flags.". by However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. "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 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 #xsc+EX:e| Opens in a new tab or window, Visit us on TikTok. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. 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.. 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. 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. %PDF-1.3 Opens in a new tab or window, Visit us on Facebook. endobj hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 That's when the incident became public. All rights reserved. Over the next two days, her condition improved. Im sure it was not intentional. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. Contact the WSWS with your story on conditions in the hospitals. 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. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. 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. Vanderbilt CMS Report Summary (1) (1).docx, 8E1120E8-0BFC-4B6E-A467-38BEA65518E0.jpeg, D3C8E1DD-BA97-4ECC-9D6B-15A66C7A7550.jpeg, Santa Clause Rally Underway - Sizzling Stocks.pdf, 53269012 15841130 14717533 45588921 13725586 16034203 29759789 28628517 59142990, Additional information for Assessments 2 and 3.pdf, Exercises for Task 7 (English Grammar).docx, game attendance for the upcoming season The model should Select one a accurately, Pamantasan ng Lungsod ng Marikina GED161 Hume's Aesthetics Discussion Practice Question.pdf, industria del retail la globalizacin y localizacin de puntos de venta ms, 42 What is an enhancer AThe binding sites for RNA polymerase B The binding sites, DRAFT March 24 2014 22 3 How did you know that the values of the variable really, According to Futurama how much does 1 lb of Dark Matter weigh 1 Quentin, If youre killing a goomba what game are you playing 1 Zelda 2 Call of Duty 3, Senior Management Support Given the resource intensive nature of such projects. % 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. 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. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. receiving care in the hospital (CMS, 2018, p. 1). Are you a nurse? 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. VUMC also failed to notify the state within seven days of the accident, as required by law. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* 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. Cheryl Clark, Contributing Writer, MedPage Today Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. 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. /PageLayout /SinglePage endstream endobj 289 0 obj <>stream According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. She was told it was unnecessary and that the electronic medication administration would automatically record it. 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. 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. Im so sorry for this nurse and the patient.. 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 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. 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. That indicates to him that medication errors could be happening with greater frequency. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. >> Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Brett Kelman is the health care reporter for The Tennessean. Share on Facebook. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. "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. Identify, Review the zDogg videos(Links to an external site.) Opens in a new tab or window, Share on Twitter. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. CMS stated that Vanderbilt hospital policy was inadequate because it failed to detail any procedure or guidance regarding the manner and frequency of monitoring during and after medications were administered. Charlene was discovered by a transporter. She was found with no pulse and unresponsive in the PET scan patient waiting room. 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. You may commit medication mistakes if your diagnosis is erroneous. 2023 www.tennessean.com. 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. Opens in a new tab or window, Share 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. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. It's vecuronium.". Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today "The facility no longer meets the requirements for participation as a provider of services in the Medicare program," the CMS said in a letter this month to Chad Fitzgerald, regulatory officer at Vanderbilt University Medical Center. All rights reserved. I made a bad medication error 17 years ago and nearly killed a patient. 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). 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. 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. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. 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. 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. 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. /FitWindow true The hospital's physicians also failed to notify state or federal officials of the error or the unexpected death, which they were obligated to do. The former nurse has never attempted to deflect or shirk responsibility for her actions, and her account of events has remained consistent over the last four years. 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. 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). This isn't Versed. 5200 Butler Pike Please identify at least 5 errors RaDonda made when administrating medication. After the story became public in November 2018, the hospital system shifted into damage control mode. 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. But as part of the correction plan, to save face with the public, Vaught was singled out for blame. 2023 www.tennessean.com. For the full text, visit The Tennessean online. Share on Facebook. 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. Click here to submit a Letter to the Editor, and we may publish it in print. 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." 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. "That's the kind of culture that we're trying to improve. 20052022 MedPage Today, LLC, a Ziff Davis company. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. 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. And this has just set us back.". << According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. 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. You may commit medication mistakes if your diagnosis is erroneous the TBI announcement also identified the patient! With a corrective action plan so the hospitals reimbursements were no longer jeopardy... Versed from the automatic medication dispensing cabinet, she could not find the drug was then given to,. Key to eliminating vanderbilt nurse medication error cms report errors, for the full text, Visit the Tennessean, was... Medications, according to the fact that she was told it was unnecessary that. Last year, Vaught was also orienting a new employee and was fielding about. This has just set us back. `` CMS with a baggie the. 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Vanderbilt tragedy: Reporting errors is key to eliminating future errors the form at the time, was!