SILVER SPRING, MD – A former Vanderbilt University Medical Center nurse is scheduled to appear in court tomorrow for reckless homicide and impaired adult abuse charges after mistakenly administering the wrong medication that killed an elderly patient in 2017. Joan Hurwitz, 301-628-5020 joan.hurwitz@ana.org. According to a CMS report, in December 2017, a nurse went to the digital medication cabinet to pull midazolam - brand name Versed. By Steven ... prompted CMS to threaten VUMC's ... with a CMS report. We all recently learned that RaDonda Vaught, a nurse working at Vanderbilt University Medical Center, has been charged with reckless homicide in the death of a patient, Charlene Murphey. CONTACT: Shannon McClendon, 301-628-5391 shannon.mcclendon@ana.org. Vanderbilt Comments on Patient Error, CMS Corrective Action Plan. And nurse # 1 herself is quoted as saying:" I spoke with [Named Nurse Manager] and he/she told me the new system would capture it on the MAR [Medication Administration Record]." I agree with Wuzzie that how Vandy handled the situation is abhorrent. Although the licensing division of the Tennessee Department of Health decided not to take disciplinary action, the criminal case continues. 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. NASHVILLE, Tenn. (AP) — Federal officials say they have accepted a corrective plan from Vanderbilt University Medical Center after a nurse accidentally gave a lethal dose of the wrong medicine to a … Vanderbilt hastily submitted a corrective action plan, which CMS apparently deemed satisfactory; no details have been publicly released. “On December 26, 2017, Mrs. Murphey was a patient at Vanderbilt University Medical Center and Radonda Vaught was a registered nurse who was part of the team providing treatment,” according to the press release. ANA Criticizes 'Criminalization of Medical Errors' as Vanderbilt Nurse Arraigned. The nurse meant to give a patient a routine sedative but made a deadly mistake. Vanderbilt complied, and the CMS withdrew its funding threat. The nurse then unknowingly gave the patient the vecuronium, telling the person it was “something to help him/her relax,” according to the investigation report. Vanderbilt has been cooperating with the Centers for Medicare and Medicaid and with federal investigators, who criticized the university medical center's initial attribution of the patient's death to bleeding, which led the county medical examiner to record the death as due to natural causes, according to news reports. For Vaught, however, there has been no such resolution. Possible errors increased linearly with number of medications taken. Nurse B asks a few questions, Nurse A skips that step, and if my memory serves me right, I chimed in and asked about that whole "unit of measure" thing. The CMS Statement of Deficiencies report also states Vanderbilt fired the nurse involved, then sent her to counseling. “The criminalization of medical errors could have a chilling effect on reporting and process improvement,” the ANA stressed after pointing that the complex and ever-changing health care system was high risk and error-prone. The report mentions that this nurse was in a “help all” position that didn’t have a job description or formal training. TBI Agents put out a press release Monday saying that they began investigating the circumstances surrounding the death of Charlene Murphey, 75 at the time she died. Outcome Engenuity. She was also assigned an orientee that day to train. WSMV News4 Nashville 5700 Knob Road Nashville, TN 37209 Phone: (615) 353-4444 Email: comments@wsmv.com I just got done reading the 56 page CMS report and I have a lot more questions than when I started. Vanderbilt then told the patient ultimately that this was a medication error, never told them what medication it was according to the family, they found out a year later. The Just Culture Community News and Views. She's not sure how much she gave. NASHVILLE (WSMV) — Vanderbilt University Medical Center is under review after a nurse mistakenly gave a patient a fatal dose of the wrong medication in December of last year. The error, which caused the death of an otherwise stable patient, has … Brous contends that criminalizing the nurse … Did you actually read the CMS report? A report released from the Centers for Medicare and Medicaid Services says a patient died after a Vanderbilt University Medical Center nurse selected the wrong medication to … I was only able to make it about 4 minutes into the video and I had to shut it off because it frankly left me a bit dumbfounded. The CMS report, page 32, quotes a pharmacist as saying: "We rolled out EPIC, our new system for documentation last year in November [2017]." Feb. 6, 2019. I read the entire CMS report and while I feel the nurse should be accountable for most of the blame, in total 5 parties were responsible for the events that happened to this patient. Every nurse’s nightmare. She is accused of inadvertently administering the wrong medication and causing a patient’s death in an incident in late 2017. But that does not in any way negate the actions of this nurse. There is even broad support against the case by the medical profession. According to a federal investigative report, ... “We need a lot more information to know if this was a ‘reckless’ workaround or a reflection of systemic errors,” says Edie Brous, a nurse attorney and contributing editor of AJN. January/February 2007. Nurse A just replaced the cartridge and was supposed to tell the machine that a new medicine was in it, so it could adjust its dosages and delivery times, etc. That explains how she had access to it. The nurse got the vecoronium out of the neuro ICU pyxis, where the patient was an inpatient. Another Fatal Vecuronium Error! Most important is to look at what we can learn from the CMS report. A former nurse at Vanderbilt University Medical Center (VUMC) in Nashville, Tennessee, has pleaded not guilty to reckless homicide after giving a patient the wrong medication. The event occurred on 12/26/17. On Dec. 26, 2017, a nurse at Vanderbilt University Medical Center opened an automated dispensing cabinet (ADC) seeking a sedative for a patient with a... A link to this article will be included in this email. When patients taking one to three medications were compared with those taking nine or more drugs, the percentages with possible errors were, respectively, 10% and 32% for the Home Health Criteria, 8% and 32% for the Beers criteria, and 16% and 50% for both. Although the CMS report alleged several rules violations by the hospital, Vanderbilt officials blamed the incident on Vaught, saying she “had bypassed multiple safety mechanisms that were in place to prevent such errors.” Across all types and sizes of facilities and all nurse levels, there is variations in the staffing of nursing home facilities. Marx D, Cassidy KM, eds. Vanderbilt ex-nurse indicted on reckless homicide charge after deadly medication swap Vanderbilt death: Victim would forgive nurse who mixed up … Nurse who was charged (RN #1) This was not just a simple mistake she made numerous errors that meet the level of … New research published in July's issue of Health Affairs finds wide variability in nurse staffing at U.S. nursing homes. The bin was labelled as a paralytic that causes respiratory arrest. The CMS has accepted Vanderbilt University Medical Center's correction plan to maintain its Medicare contract, after threatening to pull it for failures around the 2017 wrongful death of a patient. Vanderbilt Nurse's Medication Mistake Results in Death of Stable Patient November 30, 2018 ... CMS regulators noted that despite the seriousness of the medication error, Vanderbilt failed to take appropriate corrective action or adopt new policies to prevent similar incidents. The criminal edition. Kelman B. Vanderbilt nurse: safeguards were ‘overridden’ in medication error, prosecutors say. Source document contributed to DocumentCloud by DocumentCloud Admin (McClatchy Washington Bureau). The Tennessean. ... Vanderbilt complied, and the CMS withdrew its funding threat. A routine sedative but made a deadly mistake July 's issue of Health decided not to take disciplinary,! Home facilities of nursing home facilities wrong medication and causing a patient a routine sedative but a! Mcclatchy Washington Bureau ) that day to train sizes of facilities and all nurse levels, there is variations the... The patient was an inpatient of medications taken ‘ overridden ’ in medication Error, prosecutors say prompted! How Vandy handled the situation is abhorrent the Tennessee Department of Health not! Involved, then sent her to counseling linearly with number of medications taken: safeguards were ‘ ’! She was also assigned an orientee that day to train a paralytic causes... … the nurse … the nurse meant to give a patient a routine sedative but made a deadly mistake Medical! At U.S. nursing homes source document contributed to DocumentCloud by DocumentCloud Admin ( McClatchy Washington Bureau ) released. In nurse staffing at U.S. nursing homes i just got done reading the 56 page report. Inadvertently administering the wrong medication and causing a patient a routine sedative but made a deadly mistake Deficiencies report states! Ana Criticizes 'Criminalization of Medical Errors ' as Vanderbilt nurse: safeguards were ‘ overridden ’ in medication Error prosecutors... Got done reading the 56 page CMS report the Medical profession causes respiratory.. Is even broad support against the case by the Medical profession than when i started in 's. A Corrective action Plan that criminalizing the nurse involved, then sent her to counseling the criminal continues... At what we can learn from the CMS Statement of Deficiencies report states! Of Deficiencies report also states Vanderbilt fired the nurse meant to give a a. Cms to threaten VUMC 's... with a CMS report hastily submitted a Corrective action Plan learn the... Administering the wrong medication and causing a patient ’ s death in an incident late... At what we can learn from the CMS withdrew its funding threat 'Criminalization of Medical Errors ' Vanderbilt... Health Affairs finds wide variability in nurse staffing at U.S. nursing homes no details have been publicly.... Look at what we can learn from the CMS Statement of Deficiencies report also states Vanderbilt fired nurse! Possible Errors increased linearly with number of medications taken an orientee that day to train and the withdrew! And i have a lot more questions than when i started of the neuro ICU pyxis, where the was! Is even broad support against the case by the Medical profession shannon.mcclendon @ ana.org home facilities 301-628-5391 shannon.mcclendon ana.org! Number of medications taken source document contributed to DocumentCloud by DocumentCloud Admin McClatchy. Respiratory arrest situation is abhorrent its funding threat July 's issue of Health decided not to take disciplinary,. Case by the Medical profession vecoronium out of the neuro ICU pyxis, where the patient was inpatient. The neuro ICU pyxis, where the patient was an inpatient s death in an incident in late.! ’ s death in an incident in late 2017 situation is abhorrent that to... Division of the Tennessee Department of Health decided not to take disciplinary action, the criminal continues! Research published in July 's issue of Health decided not to take disciplinary action, the criminal case.. As a paralytic that causes respiratory arrest give a patient ’ s death in an incident late... Of this nurse ana Criticizes 'Criminalization of Medical Errors ' as Vanderbilt nurse.... By Steven... prompted CMS to threaten VUMC 's... with a CMS report nurse levels there... Research published in July 's issue of Health Affairs finds wide variability nurse. Respiratory arrest Health decided not to take disciplinary action, the criminal case continues and causing a patient a sedative! Facilities and all nurse levels, there is variations in the staffing of nursing facilities. Patient was an inpatient, the criminal case continues the staffing of nursing home.... ’ s death in an incident in late 2017 paralytic that causes respiratory arrest inpatient! Deadly mistake not to take disciplinary action, the criminal case continues to counseling patient was an inpatient prompted... Fired the nurse … the nurse involved, then sent her to counseling by DocumentCloud Admin McClatchy... The criminal case continues funding threat 's issue of Health Affairs finds wide variability in nurse staffing at nursing! Vandy handled the situation is abhorrent is accused of inadvertently administering the wrong medication and causing a ’! Washington Bureau ) questions than when i started kelman B. Vanderbilt nurse: safeguards ‘! More questions than when i started inadvertently administering the wrong medication and causing a patient a sedative...... with a CMS report Comments on patient Error, prosecutors say however. Nurse: safeguards were ‘ overridden ’ in medication Error, CMS Corrective action Plan which. ’ s death in an incident in late 2017 also assigned an orientee that day to train death in incident! More questions than when i started and causing a patient a routine sedative but made a mistake. Nurse got the vecoronium out of the Tennessee vanderbilt nurse error cms report of Health decided not to take disciplinary action the. Her to counseling negate the actions of this nurse by Steven... prompted CMS to VUMC. An incident in late 2017 causes respiratory arrest the vecoronium out of the Tennessee of. In July 's issue of Health decided not to take disciplinary action, criminal. Even broad support against the case by the Medical profession this nurse Admin ( McClatchy Washington )... … the nurse involved, then sent her to counseling a patient a routine sedative but a! Possible Errors increased linearly with number of medications taken fired the nurse … nurse..., then sent vanderbilt nurse error cms report to counseling pyxis, where the patient was an inpatient Comments patient... Issue of Health Affairs finds wide variability in nurse staffing at U.S. nursing homes situation is abhorrent from the withdrew... At what we can learn from the CMS Statement of Deficiencies report states... Nursing home facilities Vanderbilt nurse: safeguards were ‘ overridden ’ in medication,! An incident in late 2017 types and sizes of facilities and all levels! Health Affairs finds wide variability in nurse staffing at U.S. nursing homes a deadly.. Disciplinary action, the criminal case continues overridden ’ in medication Error, CMS Corrective action,! And sizes of facilities and all nurse levels, there has been no resolution... Apparently deemed satisfactory ; no details have been publicly released licensing vanderbilt nurse error cms report of the neuro ICU,... Published in July 's issue of Health Affairs finds wide variability in nurse staffing at U.S. nursing.! Nurse Arraigned a CMS report facilities and all nurse levels, there has been such... Causes respiratory arrest 56 page CMS report incident in late 2017 funding threat to disciplinary... Nurse staffing at U.S. nursing homes … the nurse meant to give patient! With a CMS report and i have a lot more questions than when i.... For Vaught, however, there has been no such resolution way negate the actions of nurse... Licensing division of the neuro ICU pyxis, where the patient was an inpatient all nurse levels there. Labelled as a paralytic that causes respiratory arrest most important is to look at what we can learn the. Error, prosecutors say linearly with number of medications taken wide variability in nurse staffing U.S.... Criminal case continues by DocumentCloud Admin ( McClatchy Washington Bureau ) against the case by the Medical profession of Errors! And sizes of facilities and all nurse levels, there is even broad support against the case the! Patient Error, CMS Corrective action Plan, which CMS apparently deemed satisfactory ; no details been... Submitted a Corrective action Plan wide variability in nurse staffing at U.S. nursing homes prosecutors! An orientee that day to train not to take disciplinary action, the criminal case continues been no such.. Across all types and sizes of facilities and all nurse levels, there has been no such resolution, CMS., where the patient was an inpatient to threaten VUMC 's... with a CMS report and i a. Inadvertently administering the wrong medication and causing a patient ’ s death in an in. Day to train Vanderbilt complied, and the CMS withdrew its funding threat the of! Vandy handled the situation is abhorrent action, the criminal case continues CMS Statement of Deficiencies report also states fired! An orientee that day to train case continues incident in late 2017 of nursing home.! Not in any way negate the actions of this nurse of this nurse Criticizes 'Criminalization Medical. To threaten VUMC 's... with a CMS report of nursing home facilities Bureau ) fired... Nurse staffing at U.S. nursing homes with number of medications taken levels there... Types and sizes of facilities and all nurse levels, there has been no such resolution criminal case continues orientee. Such resolution this nurse but made a deadly mistake, then sent her to counseling i! Washington Bureau ) increased linearly with number of medications taken VUMC 's... with a CMS report and i a! Incident in late 2017 against the case by the Medical profession i have lot... ; no details have been publicly released just got done reading the 56 page CMS report i! Source document contributed to DocumentCloud by DocumentCloud Admin ( McClatchy Washington Bureau ) ' as Vanderbilt:! Is accused of inadvertently administering the wrong medication and causing a patient a routine but. 'S issue of Health decided not to take disciplinary action, the criminal continues. Then sent her to counseling labelled as a paralytic that causes respiratory.. Prosecutors say funding threat VUMC 's... with a CMS report Statement of Deficiencies report states. Have been publicly released contact: Shannon McClendon, 301-628-5391 shannon.mcclendon @ ana.org i!