vanderbilt nurse medication error cms report

In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. This isn't Versed. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. 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. 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. Contact the WSWS with your story on conditions in the hospitals. 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. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. No documentation of discussions between Vanderbilt and the family is publicly available. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. Course Hero is not sponsored or endorsed by any college or university. The article entitled Paralyzed by Mistakes said that neuromuscular blocking agents like vecuronium have a well-documented history of causing catastrophic injuries or death when used in error. The article goes on to say that the most common error involving these drugs is accidental medication swaps, which are often caused by documents with look-alike names. The article specifically cites vecuronium as a dangerous drug that can be easily confused others. 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. 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. Questions 1. This is every nurses nightmare. By the definition of reckless,the defendants actions justify the charge.. 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. 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. 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. 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 Twitter. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. Identify, Review the zDogg videos(Links to an external site.) 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. 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. The hospital submitted a plan that required 330 pages to specify all the changes required. 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. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. Charlene Murphey died in the early hours of December 27, 2017. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. 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. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. She was intubated and taken to the ICU. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. 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. 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. 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. 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. endstream endobj 288 0 obj <>stream Opens in a new tab or window, Visit us on Facebook. Public records list Murphey as a 75-year-old resident of Gallatin. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. 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. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. She was told it was unnecessary and that the electronic medication administration would automatically record it. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. 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 He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. 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. Brett Kelman is the health care reporter for The Tennessean. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. /Type /Catalog Is this the med you gave (the patient? 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 After the story became public in November 2018, the hospital system shifted into damage control mode. It's vecuronium.". A criminal investigation was also initiated, and Ms. Vaught was indicted in 2019 for reckless homicide (Class D felony) and physical abuse or gross neglect of an impaired 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. 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. 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. ", 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.". 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. However, 2023 www.tennessean.com. 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. Opens in a new tab or window, Visit us on LinkedIn. Other reports document the frequency of anesthesia-related medication errors closer to home. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. The 153 events were life-threatening, 51 were significant, and 99 serious! Mistake and charging her or any other nurse with negligent homicide and was... A doctor prescribed a dose of Versed, but a nurse accidentally delivered vecuronium, an anesthetic,... Of court with Murpheys family, stipulating that the family is publicly available radiology department to receive full... Or endorsed by any college or university 27, 2017 on Twitter stipulating that the electronic medication administration automatically... 75-Year-Old resident of Gallatin college or university for PET scans was also administered the early hours December! 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