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She searched "VE" again and the cabinet produced the paralytic vecuronium. I made a bad medication error 17 years ago and nearly killed a patient. Infection prevention is important, and every hospital should have a safe injection practices policy which includes the ISMP IV Push guidelines.Learning Objectives:-Describe the CMS memos and how they impact nursing including infection controlRecall changes to medications including the timing of medication administrationDescribe that every hospital should have a safe injection practices policy that follows the CDC guidelinesRecall the impact of informed consent changes on nursingOutline:-CMS Memos of interestInsulin pensLowering humidityACA: Non-discrimination, interpretersChanges in 2020 and required signsInterpreters and low health literacyChanges to history and physicalsWho can performHealthy outpatient optionsCMS changes to the timing of medications by nursesSafe opioid use and safe blood administrationVerbal orders CMS and TJCPharmacy requirements impacting nursingReporting of medication eventsNonpunitive environmentVisitation rightsAdvocatessupport person and same-sex marriagesCMS post-anesthesia evaluationCMS restraint and seclusionReporting death with restraintsRestraint and seclusionWhat is and is not a restraintInformed consent requirementsJoint Commission RI.01.03.01CMS mandatory elementsThree CMS worksheets as self-assessment toolsInfection control and focus by CMSBreeches to be reportedSafe injection practicesCleaning equipmentInfection control standards and nursingISMP IV pushes medication guidelines and nursingCompounding and labeling medicationsMedication errorsJoint Commission and importance of documentationPatient falls, Join the Nursing & Law Navigating Problematic Nursing Chapter Standards with CMS TJC experience. 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. The most common ones involved opioids or sedative/hypnotics. You may commit medication mistakes if your diagnosis is erroneous. Murphey went into cardiac arrest and died on Dec. 27, 2017. Have an opinion about this story? 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. 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. Vaught, 36, of, 1. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. 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. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! 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. The hospital submitted a plan that required 330 pages to specify all the changes required. 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. 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 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. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. 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. Vecuronium Bromide is a potent paralytic used by an anesthesiologist when they perform intubation procedures, and the drug causes all the muscles to become paralyzed. /Pages 2 0 R Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. Opens in a new tab or window, Visit us on Twitter. 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. 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 20052022 MedPage Today, LLC, a Ziff Davis company. This article appeared on the Pharmacy Practice News website on December 15, 2022 However, VUMC policy required written documentation of the medical error in the patient record. This ruling would strip all joy from working, and it would be constant agony hoping you never mess up., Another wrote, Ive been a nurse for 35 years. However, The Institute for Safe Medicine Practices wrote last year, condemning the Tennessee Board of Nursings revocation of Vaughts license: Healthcare workers wont want to join a profession where an unintended mistake could end in the loss of their license or even jail time. Opens in a new tab or window, Visit us on Twitter. 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. Opens in a new tab or window, Share on Twitter. Public records list Murphey as a 75-year-old resident of Gallatin. endstream endobj 288 0 obj <>stream 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. centers for medicare & medicaid services omb no. You couldnt get a bag of fluids for a patient without using an override function.. 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. 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. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. 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. 1 0 obj Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. 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. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. The pandemic has only compounded the crisis in the health care sector. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. 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. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. This isn't Versed. But as part of the correction plan, to save face with the public, Vaught was singled out for blame. about the Vanderbilt case, the ISMP report, and the CMS report. 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. Institute for Safe MedicationPractices It is unlikely that these studies would have captured the kind of error that killed Murphey at Vanderbilt, however, because Murphey was getting sedation before an imaging study. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. lv[{Bbb@9\(5(it=,[0_J#1}|,_? Other reports document the frequency of anesthesia-related medication errors closer to home. Medication management is important for both CMS and the Joint Commission. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. That indicates to him that medication errors could be happening with greater frequency. That's when the incident became public. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. by "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. NEW INFO:Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say. After the story became public in November 2018, the hospital system shifted into damage control mode. However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. Opens in a new tab or window, Share on Twitter. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. This article appeared on the Pharmacy Practice News website on December 15, 2022, 20 Year CA Effort Provides Framework to Advance Prevention Strategies, Another Round of the Blame Game: A Paralyzing Criminal Indictment that Reckless, Take a Leap in Your Professional Development, Gaining Efficiencies from Vial Transfer, Admixture Devices, ISMP Encourages Adoption of Medication Error Reduction Plans, Medication Safety Officers Society (MSOS). Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. 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. We are spread too thin. 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. endstream endobj 287 0 obj <>stream The decision to criminally prosecute a former nurse at Vanderbilt University Medical Center who allegedly killed an elderly patient with a medication error is directly related to the nurse overridingsafeguards at one of the hospitals medicine dispensing cabinets. Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. 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. 286 0 obj <>stream Opens in a new tab or window, Share on LinkedIn. 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. 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. Kristina Fiore leads MedPages enterprise & investigative reporting team. 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. Follow him on Twitter at @brettkelman. 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. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. 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. xXksF_U[A[#!`+[[@/%'.sO~)yE6G>4I \oD;"+z|S?]r~^sMkNQ:Qi|w zrK-q/S1{U8+m_PHO0bx&l$E.Btn'8,PcGb*`-##w:""#3~HR: 9,J@;FH #mD="N=* It did not occur during an operating room procedure, Cole noted. Brett Kelman is the health care reporter for The Tennessean. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. 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. Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. Opens in a new tab or window, Visit us on YouTube. Cole feels the issue is critically important, but acknowledges that efforts toward improving patient safety and preventing errors within healthcare systems have died down or lost momentum in recent years, in part because of COVID. 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. Charlene Murphey died in the early hours of December 27, 2017. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. It was a big wake-up call We are human, and we get rushed, busy and distracted. 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 No documentation of discussions between Vanderbilt and the family is publicly available. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. 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. 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. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. 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. 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. 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." ANA cautions against accidental medical errors being tried in a court of law. 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. /PageMode /UseNone Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. "The facility no longer meets the requirements for participation as a provider of services in the Medicare program," the CMS said in a letter this month to Chad Fitzgerald, regulatory officer at Vanderbilt University Medical Center. It also states that the trial will be watched closely by nurses across the U.S., who are worried that a conviction may set a precedent -- particularly at a time when nurses are exhausted and demoralized, which can make them more prone to error. 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."
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