However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. 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 cost of these errors amounts to about $40 billion each year. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. "You couldn't get a bag of fluids for a patient without using an override function.". All rights reserved. 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. Opens in a new tab or window, Visit us on Facebook. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. However, All rights reserved. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. "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. 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. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. >> A second nurse found a baggie that was left over from the medicationgiven to the patient. 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. 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. Update: Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent homicide for medication error. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. "You wouldn't be able to gloss over the fine print. A nurse then went to fill this prescription from one of the hospitals electronic prescribing cabinets, which allow staff to search for medicines by name through a computer system. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. Beyond the personal aspects of these events, the prosecution of the nurse is sending waves of resentment among nurses who fear the trial will set a precedent. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. 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.. Opens in a new tab or window, Visit us on Facebook. 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. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. 2023 www.tennessean.com. Opens in a new tab or window, Share on LinkedIn. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with CMS (Center for Medicare and Medicaid Services) and the Joint Commission (TJC). /NonFullScreenPageMode /UseNone 5200 Butler Pike Share on Facebook. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. She died one day later after being taken off of a breathing machine. 20052022 MedPage Today, LLC, a Ziff Davis company. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j As a result, there was no autopsy and the death certificate did not indicate the death was accidental. 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.". 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. 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 Over the next two days, her condition improved. Vaught, who is out on bail, has declined to comment. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. She searched "VE" again and the cabinet produced the paralytic vecuronium. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. 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She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. Murphey went into cardiac arrest and died on Dec. 27, 2017. That's when the incident became public. By the definition of reckless,the defendants actions justify the charge.. At this point, the report states, the medication error was discovered. Plymouth Meeting, PA 19462. Im so sorry for this nurse and the patient.. 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. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. 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? 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. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. 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. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. 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. Follow him on Twitter at @brettkelman. /Type /Catalog This is standard practice at many hospitals, but not at VUMC. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. ~sV After the story became public in November 2018, the hospital system shifted into damage control mode. Opens in a new tab or window, Visit us on Twitter. All rights reserved. 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. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. Sentinel events, serious patient safety incidents, have reached their highest level since reporting of them began. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. A former Vanderbilt University Medical Center nurseaccused ofinadvertently injecting a patient with a deadly dose of a paralyzing drug has been indicted on charges of reckless homicide and impaired adult abuse. centers for medicare & medicaid services omb no. %PDF-1.3 If you value in-depth reporting about the issues in our community, please support our work by subscribing. 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 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. Opens in a new tab or window, Visit us on Twitter. 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