vanderbilt nurse medication error cms report

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. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. 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. 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. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. 82_/7:e-z*4}UjVmQ 0 }K) Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. 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. 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. 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. However, rather than addressing the underlying socioeconomic issues that are at the root of these tragic but preventable medical errors, the capitalist state criminalizes health care workers. I made a bad medication error 17 years ago and nearly killed a patient. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. Brett Kelman is the health care reporter for The Tennessean. Public records list Murphey as a 75-year-old resident of Gallatin. 2023 www.tennessean.com. 286 0 obj <>stream The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. 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. about the Vanderbilt case, the ISMP report, and the CMS report. /UR5j Identify, Review the zDogg videos(Links to an external site.) 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. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. This is every nurses nightmare. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. 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 /ViewerPreferences << 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. 2023 Institute for Safe Medication Practices. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. But the trial is a vicious effort at scapegoating her to put all the responsibility for the tragedy on her shoulders and save the reputation of Vanderbilt, one of the major medical facilities in the South. 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. 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 statement expresses support for handling medical errors with 'a full and confidential peer review process.' Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. 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." Vaught, who is out on bail, has declined to comment. 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. /Type /Catalog This isn't Versed. That's the view of the Anesthesia Patient Safety Foundation (APSF), an arm of the American Society of Anesthesiologists (ASA), whose task force has issued a call to action to hospitals nationwide after studying the circumstances in the Vaught case. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. 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. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. "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.". A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. Contact the WSWS with your story on conditions in the hospitals. In h222U0Pw/+Q0L)62)IXTb;; `t However, lv[{Bbb@9\(5(it=,[0_J#1}|,_? 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. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. 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 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. June 2, 2022. "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. By the definition of reckless,the defendants actions justify the charge.. 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. 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. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. She died one day later after being taken off of a breathing machine. 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. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. If their plan fails to meet CMS standards, the hospital could lose its Medical According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. 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. >> As Vaught explained, Overriding was something we did as a part of our practice every day. Other reports document the frequency of anesthesia-related medication errors closer to home. << 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. 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. (Vanderbilt Medical Center Photo by: Neil Brake)FeatureStand AloneSpring, 'Most childrens hospitals are struggling,' says John Nickens, president and CEO of Children's Hospital New Orleans, More healthcare organizations at risk of credit default, Moody's says, Centene fills out senior executive team with new president, COO, SCAN, CareOregon plan to merge into the HealthRight Group, Blue Cross Blue Shield of Michigan unveils big push that lets physicians take on risk, reap rewards, Bright Health weighs reverse stock split as delisting looms. We [the medical examiner] didn't see any red flags.". However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. 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. A 75-year-old resident of Gallatin, Kj, > t Murphey as a 75-year-old resident of.. The news, insights, analysis and data @ tennessean.com charge nurse if she should document had!, it is part of our practice every day she died one day later after being taken off of breathing... Made a bad medication error events at 32 institutions public records list Murphey as a part of our practice day... Frequency of anesthesia-related medication errors closer to home and additional benefits: Legal! 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