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 Please Watch short YouTube video first, length: 2:32, The Centers for Medicare and Medicaid Services (CMS) report is summarized here and the, events are described via interviews with the involved parties. stream 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. 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. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. As Vaught explained, Overriding was something we did as a part of our practice every day. /Pages 2 0 R Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. Murphey went into cardiac arrest and died on Dec. 27, 2017. Opens in a new tab or window, Share on LinkedIn. At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j She was discovered 30 minutes later without a pulse, not breathing and unresponsive. /NonFullScreenPageMode /UseNone April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. 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 "That's the kind of culture that we're trying to improve. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. 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 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. An IOM study found that a hospital patient is subject to one medication error per day. The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. 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. 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt Opens in a new tab or window. Dangerous medication errors are also found in pediatric care settings. She was told it was unnecessary and that the electronic medication administration would automatically record it. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. After the story became public in November 2018, the hospital system shifted into damage control mode. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. 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. Almost 10 months later, an anonymous complainant tipped off the Centers for Medicare & Medicaid Services (CMS), giving an accurate description of the event, and concluding that VUMC had failed to report the event to the state, as required. 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. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. 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. You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. 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. ~sV /FitWindow true Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. 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 Opens in a new tab or window, Visit us on Facebook. 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. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. against Nurse Vaught. And this has just set us back.". He pointed to a 2019 paper in the British Journal of Anaesthesia that chronicled 7,072 provider-reported incidents in 104 hospitals in which a patient could have been or was harmed during a hospital procedure over a 10-year period in Chile and Spain. She died one day later after being taken off of a breathing machine. 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. The CMS report also notes that the information provided to the family indicates that the cause of death was worded as possibly being due to a medical error. 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. 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. The pandemic has only compounded the crisis in the health care sector. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! Im so sorry for this nurse and the patient.. She was on duty covering the day shift on December 25 and 26, 2017, as the Help All nurse in the Neuro Intensive Care Unit. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. "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. "You couldn't get a bag of fluids for a patient without using an override function.". Identify, Review the zDogg videos(Links to an external site.) 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. However, further evaluation revealed she had suffered an extensive brain injury from a prolonged lack of oxygen with a very low likelihood of neurological recovery. Later that evening, after speaking with the critical care team, the family agreed that the best course of action was to withdraw all care. Opens in a new tab or window, Visit us on TikTok. Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. endstream endobj 287 0 obj <>stream This is standard practice at many hospitals, but not at VUMC. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. 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. 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The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. 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. Institute for Safe MedicationPractices Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. << Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. >> Vaught was assigned to pick up the medication from the dispensing cabinet and administer it in the radiology department to Murphey before her PET scan. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. ( Links to an external site. Vaught explained, Overriding was something we did a. Sedative to calm her nerves in November 2018, VUMC settled out court... Standard practice at many hospitals, but not at VUMC or window, Visit on... Or atbrett.kelman @ tennessean.com stream this is standard practice at many hospitals but! Using an override function. `` been made did as a part of our practice every day from... 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