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. Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. 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. Kristina Fiore leads MedPages enterprise & investigative reporting team. %PDF-1.3 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. 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. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. 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. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. 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. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. This ruling would strip all joy from working, and it would be constant agony hoping you never mess up., Another wrote, Ive been a nurse for 35 years. against Nurse Vaught. Share on Facebook. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. endobj ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. 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? According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. 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. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. June 2, 2022. Over the next two days, her condition improved. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j "But there is a big push right now to reignite this effort.". >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. /PageMode /UseNone Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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. 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. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Follow him on Twitter at @brettkelman. Despite numerous requests, the corrective action plan has not been made public by the federal government. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. ~sV Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. ", 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.". 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. 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. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. endstream endobj 288 0 obj <>stream Instead, Murphey was left alone as Vaught was called away to the emergency room. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. % 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 patients primary nurse was not available at the time. Medication errors are the most common type of medical error. The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. 2023 Institute for Safe Medication Practices. 2023 www.tennessean.com. State surveyors made an unannounced visit to the academic medical center late last month and learned that a patient died after receiving not only the wrong medication, but a high dose of the errant drug as well, according to a report given exclusively to Modern Healthcare by the CMS. Opens in a new tab or window, Visit us on TikTok. However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. 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. Opens in a new tab or window. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. 286 0 obj <>stream 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. 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. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. The state of Tennessee also revoked her nursing license. The report said someone should have stayed with Murphey after she received the drug in case of adverse reactions, which were not detected for 30 minutes, constituting "neglect" of the patient and violating her rights. An entirely preventable error results in a horrific death at a major medical institution. 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. >> 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 TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. 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. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. He became extremely symptomatic at work and was brought to your emergency department. 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. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. Nurses have previously rallied in support of Vaught. NEW INFO:Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say. This article appeared on the Pharmacy Practice News website on December 15, 2022 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. by about the Vanderbilt case, the ISMP report, and the CMS report. The most common ones involved opioids or sedative/hypnotics. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. This severe error was largely foreseeable and preventable, according to the Institute for Safe Medication Practices, which published an 2016 article describing almost the exact circumstances of Murpheys death. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! 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. "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. 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 . 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. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. 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. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with 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. Opens in a new tab or window, Visit us on Facebook. That's when the incident became public. 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. 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 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. If their plan fails to meet CMS standards, the hospital could lose its Medical 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. Opens in a new tab or window, Share on LinkedIn. 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. And this has just set us back.". 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. 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. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. 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 20052022 MedPage Today, LLC, a Ziff Davis company. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. Sign up for the WSWS Health Care Workers Newsletter! 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! 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. 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 Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. Opens in a new tab or window, Visit us on LinkedIn. The pandemic has only compounded the crisis in the health care sector. 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 Opens in a new tab or window, Visit us on Instagram. "You wouldn't be able to gloss over the fine print. receiving care in the hospital (CMS, 2018, p. 1). "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. endstream endobj 289 0 obj <>stream The agency spent days questioning Vanderbilt personnel and found problems so serious, it threatened to revoke the system's Medicare reimbursement unless it took corrective action. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. Opens in a new tab or window, Visit us on Twitter. 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. "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.". For the full text, visit The Tennessean online. Opens in a new tab or window, Visit us on LinkedIn. Are you a nurse? "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. 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. by /PageLayout /SinglePage The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. 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. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. 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