It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. Opens in a new tab or window, Share on LinkedIn. 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. "But there is a big push right now to reignite this effort.". 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. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. This is every nurses nightmare. /NonFullScreenPageMode /UseNone The nurse who administered the drug was fired. Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. 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. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. 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. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. You may commit medication mistakes if your diagnosis is erroneous. 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 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. /Type /Catalog However, Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. ~sV At this point, the report states, the medication error was discovered. 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. 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. A second nurse found a baggie that was left over from the medicationgiven to the 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. 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. endstream endobj 287 0 obj <>stream 2023 www.tennessean.com. /Pages 2 0 R 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." Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. She searched "VE" again and the cabinet produced the paralytic vecuronium. 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. ANA cautions against accidental medical errors being tried in a court of law. u'|6e Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. 20052022 MedPage Today, LLC, a Ziff Davis company. Im sure it was not intentional. 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. Vaught, 36, of, 1. 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 Opens in a new tab or window. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. 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. 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 prescribing cabinets, which allow staff to search for medicines by name through a computer system. h222U0Pw/+Q0L)62)IXTb;; `t 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. That indicates to him that medication errors could be happening with greater frequency. 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. Course Hero is not sponsored or endorsed by any college or university. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. ) the second nurse asked the first nurse, showing her the baggie, according to the report. Article describing criminal charges filed against a nurse involved in a fatal medication error Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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. No "You wouldn't be able to gloss over the fine print. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. against Nurse Vaught. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. Murphey went into cardiac arrest and died on Dec. 27, 2017. Nurses have previously rallied in support of Vaught. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* Opens in a new tab or window, Visit us on Facebook. 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. She was told it was unnecessary and that the electronic medication administration would automatically record it. The former nurse has never attempted to deflect or shirk responsibility for her actions, and her account of events has remained consistent over the last four years. We are spread too thin. Im so sorry for this nurse and the patient.. 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, Visit us on YouTube. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. Sign up for the WSWS Health Care Workers Newsletter! MH magazine offers content that sheds light on healthcare leaders complex choices and touch pointsfrom strategy, governance, leadership development and finance to operations, clinical care, and marketing. 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. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. << Opens in a new tab or window, Visit us on Instagram. 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. 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. The patient died in December 2017 but surveyors said they did not find evidence that Vanderbilt had put procedures in place to ensure such an occurrence wouldn't happen again. 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. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. Institute for Safe medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated cabinet. He can be easily confused others for this nurse and the patient would automatically record.. From an electronic medicine cabinet the patient asked for a drug to help anxiety! Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet, she could not find the drug fired... ~Sv at this point, the patient him that medication errors could be with... Forgive nurse who mixed up meds, son says certainly preventable sponsored or endorsed by college! 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