The death ultimately triggered aninvestigation by the Centers for Medicare and Medicaid Services, which said in November it might suspendVanderbilt's Medicare reimbursement payments, which amount to about one fifth ofhospital revenue. VUMC also failed to notify the state within seven days of the accident, as required by law. 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 . 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. Opens in a new tab or window, Visit us on TikTok. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. 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. 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. /Length 2913 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 Twitter. about the Vanderbilt case, the ISMP report, and the CMS report. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. Vaught, 36, of, 1. lv[{Bbb@9\(5(it=,[0_J#1}|,_? 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. Im sure it was not intentional. 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. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. 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.. Contact the WSWS with your story on conditions in the hospitals. Brett Kelman is the health care reporter for The Tennessean. CMS stated that Vanderbilt hospital policy was inadequate because it failed to detail any procedure or guidance regarding the manner and frequency of monitoring during and after medications were administered. Charlene was discovered by a transporter. She was found with no pulse and unresponsive in the PET scan patient waiting room. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. In early 2018, the hospital negotiated an out-of-court settlement with Murphey's family that required them not to speak publicly about the death or the error, the Tennessean reported. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. She died one day later after being taken off of a breathing machine. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. >> When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. She was publicly identified for the first time when she was arrested February 4, 2019 and charged with reckless homicide carrying a possible jail sentence of more than 10 years. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. Identify, Review the zDogg videos(Links to an external site.) The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. For the full text, visit The Tennessean online. /Type /Catalog 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. Sign up for the WSWS Health Care Workers Newsletter! Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! Questions 1. 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 became extremely symptomatic at work and was brought to your emergency department. 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. She then typed the first two letters in the drugs name VE into the cabinet and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed. 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. NEW INFO:Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say. 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. Brett Kelman is the health care reporter for The Tennessean. %PDF-1.6 % The health care executives who have the final say in safety policies at Vanderbilt were found negligent by the Centers for Medicare and Medicaid Services, but they have not been held to account by the prosecutors office. 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. /NonFullScreenPageMode /UseNone All rights reserved. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. Cheryl Clark, Contributing Writer, MedPage Today 2023 Institute for Safe Medication Practices. We are spread too thin. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. In When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. This is standard practice at many hospitals, but not at VUMC. 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. At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. 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. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. 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. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. A second nurse found a baggie that was left over from the medicationgiven to the patient. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. If you value in-depth reporting about the issues in our community, please support our work by subscribing. 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. "Yes, we have lost some mojo, the pandemic being one reason," he said. 20052022 MedPage Today, LLC, a Ziff Davis company. In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. 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. Institute for Safe MedicationPractices 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? Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. At this point, the report states, the medication error was discovered. All rights reserved. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. << The physician responsible for contacting the Davidson County Medical Examiner failed to inform them that the cause of death was an inadvertent administration of a paralytic agent. 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. Opens in a new tab or window, Visit us on Facebook. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. She searched "VE" again and the cabinet produced the paralytic vecuronium. /Filter [ /FlateDecode ] patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). Opens in a new tab or window, Share on Twitter. "You wouldn't be able to gloss over the fine print. 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 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. No documentation of discussions between Vanderbilt and the family is publicly available. Opens in a new tab or window, Visit us on YouTube. 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 timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. The patients primary nurse was not available at the time. 2023 www.tennessean.com. 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. 82_/7:e-z*4}UjVmQ 0 }K) 286 0 obj <>stream 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. VUMC quickly distanced itself from the incident. 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. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. Despite the requirement that the county medical examiner be notified in the case of unusual or unexpected deaths -- which many patient safety advocates say would detect fixable hospital errors and provide accountability -- hospital officials instead attributed her death to her brain bleed rather than a medication error. Opens in a new tab or window, Visit us on LinkedIn. 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. Follow him on Twitter at @brettkelman. https://www.youtube.com/watch?v=ZrpzNVBgTT8 Define high reliability, Describe how you achieved each course competency, including at least one example of new knowledge gained related to that competency. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. March 23, 2022. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. However, VUMC policy required written documentation of the medical error in the patient record. Follow. The medical examiner told federal investigators that the office "released jurisdiction (did not investigate the death or perform an autopsy on patient Murphey) because there was an MRI that confirmed the bleed." Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. It did not occur during an operating room procedure, Cole noted. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. Sentinel events, serious patient safety incidents, have reached their highest level since reporting of them began. 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 Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. Opens in a new tab or window, Visit us on Twitter. She was intubated and taken to the ICU. The nurse who administered the drug was fired. inadvertently injecting a patient with a deadly dose of a paralyzing drug, Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say, Victim would forgive nurse who mixed up meds, son says, Vanderbilt didnt tell medical examiner about deadly medication error, feds say, Your California Privacy Rights / Privacy Policy. It's clear from federal documents addressing the 2017 incident that Vaught is hardly the only one who made mistakes that endangered Vanderbilt patients' lives. 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