2023 www.tennessean.com. 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.. 2023 www.tennessean.com. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. June 2, 2022. We are spread too thin. Additionally, interpreters and low health literacy will be discussed to help hospitals comply with CMS and Joint Commission standards and compliance with the OCR Section 1557 on signage, patient rights, nondiscrimination, qualified interpreters, and 2020 changes. 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. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. She died one day later after being taken off of a breathing machine. /Length 2913 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 However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. Dangerous medication errors are also found in pediatric care settings. 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. Questions 1. The pandemic has only compounded the crisis in the health care sector. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 Contact the WSWS with your story on conditions in the hospitals. Opens in a new tab or window, Visit us on TikTok. Nurses have previously rallied in support of Vaught. But as part of the correction plan, to save face with the public, Vaught was singled out for blame. The medication error occurred on Dec. 26, 2017while Murphey was being treated at Vanderbilt for a subdural hematoma that was causing a headache and loss of vision. At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. 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. 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. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. 1 0 obj Opens in a new tab or window, Share on Twitter. 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. "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. For the full text, visit The Tennessean online. Over the next two days, her condition improved. 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. 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 Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. 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. 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. This is every nurses nightmare. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. Are you a nurse? In 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 believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. 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. An IOM study found that a hospital patient is subject to one medication error per day. 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. Murphey went into cardiac arrest and died on Dec. 27, 2017. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. This CONDITION is not met as evidenced by: Based on policy review, medical record review, and interview, the hospital failed to ensure patients rights were protected to receive care in a safe setting and implemented measures to mitigate risks of potentially fatal medication errors to the patients receiving care in the hospital. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. At this point, the report states, the medication error was discovered. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. All rights reserved. ", Additionally, said Cole, hospitals could institute a policy requiring a "period of monitoring by a qualified practitioner" so that patients aren't just given a medication like the sedative midazolam (Versed) -- which Murphey was supposed to get to calm her anxiety ahead of a PET scan -- "and then sent to a corner somewhere.". She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. Charlene Murphey died in the early hours of December 27, 2017. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. /Filter [ /FlateDecode ] Since she couldnt find the Versed in the AccuDose system, she overrode the system, typed in VE, and selected the first medication (Vecuronium Bromide) in the list. 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. 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. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. 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. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering 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. The agency spent days questioning Vanderbilt personnel and found problems so serious, it threatened to revoke the system's Medicare reimbursement unless it took corrective action. by Opens in a new tab or window, Visit us on YouTube. It was a big wake-up call We are human, and we get rushed, busy and distracted. 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). The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with Vanderbilt CMS Report Summary (1) (1).docx, 8E1120E8-0BFC-4B6E-A467-38BEA65518E0.jpeg, D3C8E1DD-BA97-4ECC-9D6B-15A66C7A7550.jpeg, Santa Clause Rally Underway - Sizzling Stocks.pdf, 53269012 15841130 14717533 45588921 13725586 16034203 29759789 28628517 59142990, Additional information for Assessments 2 and 3.pdf, Exercises for Task 7 (English Grammar).docx, game attendance for the upcoming season The model should Select one a accurately, Pamantasan ng Lungsod ng Marikina GED161 Hume's Aesthetics Discussion Practice Question.pdf, industria del retail la globalizacin y localizacin de puntos de venta ms, 42 What is an enhancer AThe binding sites for RNA polymerase B The binding sites, DRAFT March 24 2014 22 3 How did you know that the values of the variable really, According to Futurama how much does 1 lb of Dark Matter weigh 1 Quentin, If youre killing a goomba what game are you playing 1 Zelda 2 Call of Duty 3, Senior Management Support Given the resource intensive nature of such projects. All rights reserved. "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. >> Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. 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. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. Follow him on Twitter at @brettkelman. 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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