Medication management is important for both CMS and the Joint Commission. 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. Im sure it was not intentional. The patients primary nurse was not available at the time. Opens in a new tab or window, Visit us on YouTube. During an unannounced on-site survey of Vanderbilt University Medical Center in November, CMS learned a patient died at the hospital in December 2017 due to a medication error. 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. 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. 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. Opens in a new tab or window, Share on LinkedIn. 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. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. A second nurse found a baggie that was left over from the medicationgiven to the patient. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with 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. As Hospital Watchdog noted, Its only natural to wonder if Vanderbilt, an extremely influential political entity, gave a quiet thumbs up behind closed doors to proceed with a prosecution against one of its nurses. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. 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. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. Follow him on Twitter at @brettkelman. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today Plymouth Meeting, PA 19462. 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. "You couldn't get a bag of fluids for a patient without using an override function.". "You wouldn't be able to gloss over the fine print. 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 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. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. "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. An IOM study found that a hospital patient is subject to one medication error per day. It's vecuronium.". 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. 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. 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. Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. 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. endstream endobj 288 0 obj <>stream I made a bad medication error 17 years ago and nearly killed a patient. Share on Facebook. 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 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. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. Opens in a new tab or window, Visit us on Facebook. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. Follow him on Twitter at @brettkelman. Brett Kelman is the health care reporter for The Tennessean. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. The CMS is threatening to strip Vanderbilt University Medical Center in Nashville, of its ability to care for Medicare patients because a patient died after receiving a large dose of the wrong medication. 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. No 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 nurse then typed the first two letters in the drugs name VE into the cabinet computer and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed. 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. 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.. However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. /PageLayout /SinglePage However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. (Vanderbilt Medical Center Photo by: Neil Brake)FeatureStand AloneSpring, 'Most childrens hospitals are struggling,' says John Nickens, president and CEO of Children's Hospital New Orleans, More healthcare organizations at risk of credit default, Moody's says, Centene fills out senior executive team with new president, COO, SCAN, CareOregon plan to merge into the HealthRight Group, Blue Cross Blue Shield of Michigan unveils big push that lets physicians take on risk, reap rewards, Bright Health weighs reverse stock split as delisting looms. All rights reserved. Despite numerous requests, the corrective action plan has not been made public by the federal government. 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. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' Charlene Murphey died in the early hours of December 27, 2017. Are you a nurse? 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. Over the next two days, her condition improved. Despite numerous advances in anesthesia safety over the years, former Tennessee nurse RaDonda Vaught's deadly medication error could have been prevented with a few system-wide fixes that aren't that difficult or costly. Opens in a new tab or window, Visit us on LinkedIn. All rights reserved. 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. All rights reserved. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. "The error occurred because a staff member had bypassed multiple safety mechanisms that were in place to prevent such errors," said Vanderbilt Spokesman John Howser. 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. 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