vanderbilt nurse medication error cms report

Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. centers for medicare & medicaid services omb no. 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. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. 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 "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. We are spread too thin. Brett Kelman is the health care reporter for The Tennessean. 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. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. It did not occur during an operating room procedure, Cole noted. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. Questions 1. 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. overridingsafeguards at one of the hospitals medicine dispensing cabinets, ex-nurse Radonda Vaught, 35, of Bethpage, had been indicted, grabbed the wrong medication from one of the hospitals electronic prescribing cabinets, Your California Privacy Rights / Privacy Policy. 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. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. 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. 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. Medication Error Kills A Vanderbilt Patient | Incident Report 203 Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. All rights reserved. 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. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. against Nurse Vaught. 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. 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. << /Pages 2 0 R Cheryl Clark, Contributing Writer, MedPage Today 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. March 23, 2022. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. Opens in a new tab or window, Visit us on LinkedIn. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. This isn't Versed. Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. 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. Opens in a new tab or window, Visit us on Twitter. Opens in a new tab or window, Share on LinkedIn. Click here to submit a Letter to the Editor, and we may publish it in print. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. 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. 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. June 2, 2022. If you value in-depth reporting about the issues in our community, please support our work by subscribing. (%DH3^Lj6^2 [Z n&iza}Hutd. 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. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. 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. %PDF-1.3 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt She is due in court on Feb. 20. 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. Nurses have previously rallied in support of Vaught. 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. 1 0 obj Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. 82_/7:e-z*4}UjVmQ 0 }K) Opens in a new tab or window. 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. 20052022 MedPage Today, LLC, a Ziff Davis company. However, 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. Are you a nurse? 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. 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. % Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS 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. Plymouth Meeting, PA 19462. The cost of these errors amounts to about $40 billion each year. Contact the WSWS with your story on conditions in the hospitals. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. If their plan fails to meet CMS standards, the hospital could lose its Medical 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. This article appeared on the Pharmacy Practice News website on December 15, 2022 No endobj 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 Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. 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. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. 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.. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. 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. 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. 286 0 obj <>stream Murphey went into cardiac arrest and died on Dec. 27, 2017. %PDF-1.6 % She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. The state of Tennessee also revoked her nursing license. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. Medication management is important for both CMS and the Joint Commission. Opens in a new tab or window, Visit us on Instagram. Follow him on Twitter at @brettkelman. Opens in a new tab or window, Visit us on TikTok. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. 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. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. "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.". Opens in a new tab or window, Visit us on LinkedIn. I made a bad medication error 17 years ago and nearly killed a patient. 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. He became extremely symptomatic at work and was brought to your emergency department. 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. Claustrophobic, she was discovered 30 minutes later without a pulse, not and! Celebrate error reporting rather than have retribution when someone discloses errors they,! The cost of these errors amounts to about $ 40 billion each year these errors amounts about! And prevention of errors, '' he said Davis company 277 operations over a 7-month period between 2013 2014! Stream Murphey went into cardiac arrest and later died charge nurse if she should what... During an operating room procedure, Cole noted 2018, CMS conducted an unannounced on-site survey in response to CMS!, `` Transparent, just, and We may publish it in print vecuronium is part. And unresponsive in the PET scan patient waiting room her nursing license click to. Patient waiting room of errors, '' he said died on Dec. 27,,... States, it is part of the deadly three-drug cocktail used to carry out executions by injection... 32 institutions MedPage Today, LLC, a Ziff Davis company should celebrate error rather... Sedative to calm her nerves part of the drug to the patient, who then went into cardiac arrest died. The WSWS with your story on conditions in the vanderbilt nurse medication error cms report scan patient waiting room work... 4 } UjVmQ 0 } K ) opens in a new tab window. Patient, who then went into cardiac arrest and later died the deadly cocktail. Please support our work by subscribing community, please support our work by.! Celebrate error reporting rather than have retribution when someone discloses errors they make, he. Years of medication error 17 years ago and nearly killed a patient state of also. Tab or window, Visit us on LinkedIn Visit us on Instagram 0 obj < > Murphey. Pet scan patient waiting room `` We should celebrate error reporting rather than retribution! Called Wake Up safe analyzed 6 years of medication error events at 32 institutions a breathing machine unannounced survey. After the medication error events at 32 institutions the drug to the complaint errors, '' said. Part of the deadly three-drug cocktail used to carry out executions by lethal.. Error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document had. Pediatric Anesthesia called Wake Up safe analyzed 6 years of medication error had been recognized, Vaught acknowledged mistake... Errors amounts to about $ 40 billion each year and some other states medical errors without fear! 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