Charlene Murphey died in the early hours of December 27, 2017. 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 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. She is due in court on Feb. 20. "You couldn't get a bag of fluids for a patient without using an override function.". No documentation of discussions between Vanderbilt and the family is publicly available. 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. Opens in a new tab or window, Visit us on Twitter. That's when the incident became public. 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. 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. by Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. 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. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. Opens in a new tab or window, Share on LinkedIn. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j The system asked for a reason for the override, but she couldnt recall what reason she selected., Due to problems with communication between electronic health records, medication dispensing cabinets, and the hospital pharmacy that were causing delays in administering medications, the hospital was using workarounds that overrode the safeguards built into the medicine cabinets so staff could access drugs quickly when needed. 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. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. 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. A second nurse found a baggie that was left over from the medicationgiven to the patient. All rights reserved. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering All rights reserved. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. ANA cautions against accidental medical errors being tried in a court of law. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. 5200 Butler Pike 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. The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. 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. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. Opens in a new tab or window, Visit us on Instagram. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. "The failure of the hospital to mitigate risks associated with medication errors and ensure all patients received care in a safe setting placed them in immediate jeopardy and risk of serious injuries or death," the CMS said in the report. << Opens in a new tab or window, Visit us on YouTube. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* 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. 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. Update: Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent homicide for medication error. 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. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. 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. Instead, Murphey was left alone as Vaught was called away to the emergency room. 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. Nurses have previously rallied in support of Vaught. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. 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. 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." As a result, there was no autopsy and the death certificate did not indicate the death was accidental. /UR5j The hospital submitted a plan that required 330 pages to specify all the changes required. 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 Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. 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. Vaught became a registered nurse in February 2015. Almost 10 months later, an anonymous complainant tipped off the Centers for Medicare & Medicaid Services (CMS), giving an accurate description of the event, and concluding that VUMC had failed to report the event to the state, as required. 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. June 2, 2022. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. 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=* Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. 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. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. The most common ones involved opioids or sedative/hypnotics. 2023 www.tennessean.com. Please Watch short YouTube video first, length: 2:32, The Centers for Medicare and Medicaid Services (CMS) report is summarized here and the, events are described via interviews with the involved parties. 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. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. ) the second nurse asked the first nurse, showing her the baggie, according to the report. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! 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. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. Click here to submit a Letter to the Editor, and we may publish it in print. 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. >> You couldnt get a bag of fluids for a patient without using an override function.. 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. VUMC quickly distanced itself from the incident. 20052022 MedPage Today, LLC, a Ziff Davis company. "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. /Pages 2 0 R 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. Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year.
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