Have an opinion about this story? 20052022 MedPage Today, LLC, a Ziff Davis company. 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. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. 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 It also states that the trial will be watched closely by nurses across the U.S., who are worried that a conviction may set a precedent -- particularly at a time when nurses are exhausted and demoralized, which can make them more prone to error. 20052022 MedPage Today, LLC, a Ziff Davis company. She was told it was unnecessary and that the electronic medication administration would automatically record it. 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. 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 . 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. No 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. 2023 www.tennessean.com. RaDonda Vaught, 38, was charged in 2019 with reckless homicide and impaired adult abuse after she allegedly gave 75-year-old Charlene Murphey the paralytic vecuronium when she was meant to give her the sedative midazolam (Versed) for her anxiety ahead of a PET scan. 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. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. 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. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Opens in a new tab or window, Visit us on Twitter. Opens in a new tab or window, Share on LinkedIn. ", Additionally, said Cole, hospitals could institute a policy requiring a "period of monitoring by a qualified practitioner" so that patients aren't just given a medication like the sedative midazolam (Versed) -- which Murphey was supposed to get to calm her anxiety ahead of a PET scan -- "and then sent to a corner somewhere.". Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today 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. /PageMode /UseNone 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. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. by Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. h222U0Pw/+Q0L)62)IXTb;; `t
Follow him on Twitter at @brettkelman. Nurses have previously rallied in support of Vaught. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. 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. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. The nurse who administered the drug was fired. Follow. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. The Institute for Safe Medicine Practices wrote last year, condemning the Tennessee Board of Nursings revocation of Vaughts license: Healthcare workers wont want to join a profession where an unintended mistake could end in the loss of their license or even jail 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? 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. 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. >> All rights reserved. "You couldn't get a bag of fluids for a patient without using an override function.". /Pages 2 0 R 82_/7:e-z*4}UjVmQ 0 }K)
Kristina Fiore leads MedPages enterprise & investigative reporting team. Update: Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent homicide for medication error. 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. Opens in a new tab or window, Visit us on LinkedIn. 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. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. 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. You may commit medication mistakes if your diagnosis is erroneous. 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. ANA maintains that this tragic incident must serve as reminder that vigilance and open collaboration among regulators, administrators, and health care teams is critical at the patient and system level to continue to provide high-quality care.". 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. 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. You couldnt 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. 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. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. 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. 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. 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. 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. 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. Is this the med you gave (the patient? #xsc+EX:e| Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. /Type /Catalog Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. 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. Opens in a new tab or window, Visit us on TikTok. 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. 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." The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. Opens in a new tab or window, Visit us on Twitter. /NonFullScreenPageMode /UseNone Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. For the full text, visit The Tennessean online. After the story became public in November 2018, the hospital system shifted into damage control mode. 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. She then typed the first two letters in the drugs name VE into the cabinet and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed. The medical examiner told investigators that the Vanderbilt physician who reported her death said, "maybe there was a medication error, but that was hearsay, nothing has been documented. "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.". Despite numerous advances in anesthesia safety over the years, former Tennessee nurse RaDonda Vaught's deadly medication error could have been prevented with a few system-wide fixes that aren't that difficult or costly. 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. 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. about the Vanderbilt case, the ISMP report, and the CMS report. 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. 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. Opens in a new tab or window, Visit us on Instagram. Steve Hayslip, a spokesman for the Davidson County District Attorneys Office, said in a brief statement on Wednesday that prosecutors were barred from publicly discussing the merits of the case, but that the override was central to the charge of reckless homicide. This article appeared on the Pharmacy Practice News website on December 15, 2022 Murphey went into cardiac arrest and died on Dec. 27, 2017. 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. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. The state of Tennessee also revoked her nursing license. 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. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. If you are going to do that, you should put all of the administrators at Vanderbiltwho are overseeing her, who are overseeing safety, who are responsible for communicating with CMS and with the patientthey should all go to jail.. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. Follow him on Twitter at @brettkelman. We [the medical examiner] didn't see any red flags.". Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. 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. 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 The decision to criminally prosecute a former nurse at Vanderbilt University Medical Center who allegedly killed an elderly patient with a medication error is directly related to the nurse overridingsafeguards at one of the hospitals medicine dispensing cabinets. Opens in a new tab or window, Share on Twitter. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. ANA cautions against accidental medical errors being tried in a court of law. 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. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. At this point, the report states, the medication error was discovered. Over the next two days, her condition improved. Cheryl Clark, Contributing Writer, MedPage Today Opens in a new tab or window, Visit us on Instagram. Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. Opens in a new tab or window, Visit us on YouTube. /ViewerPreferences << 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. 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. It was a big wake-up call We are human, and we get rushed, busy and distracted. 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 Vaught, who is out on bail, has declined to comment. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! 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. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. Opens in a new tab or window, Visit us on LinkedIn. The cost of these errors amounts to about $40 billion each year. Vaught, 36, of, 1. >> 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. I made a bad medication error 17 years ago and nearly killed a patient. Opens in a new tab or window, Share on Twitter. This is every nurses nightmare. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with Opens in a new tab or window, Visit us on Facebook. 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. 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. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. 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. An entirely preventable error results in a horrific death at a major medical institution. Instead, Murphey was left alone as Vaught was called away to the emergency room. If you value in-depth reporting about the issues in our community, please support our work by subscribing. Brett Kelman is the health care reporter for The Tennessean. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' 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. Opens in a new tab or window, Visit us on TikTok. "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. The patients primary nurse was not available at the time. Charlene Murphey died in the early hours of December 27, 2017. 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. "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. 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. lv[{Bbb@9\(5(it=,[0_J#1}|,_? 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. She joined the prestigious Vanderbilt University Medical Center in October 2015. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. 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