WSMV News4 Nashville 5700 Knob Road Nashville, TN 37209 Phone: (615) 353-4444 Email: comments@wsmv.com ANA Criticizes 'Criminalization of Medical Errors' as Vanderbilt Nurse Arraigned. The criminal edition. The nurse meant to give a patient a routine sedative but made a deadly mistake. She is accused of inadvertently administering the wrong medication and causing a patient’s death in an incident in late 2017. 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. 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 … Nurse who was charged (RN #1) This was not just a simple mistake she made numerous errors that meet the level of … Joan Hurwitz, 301-628-5020 joan.hurwitz@ana.org. I agree with Wuzzie that how Vandy handled the situation is abhorrent. Feb. 6, 2019. According to a CMS report, in December 2017, a nurse went to the digital medication cabinet to pull midazolam - brand name Versed. 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. Kelman B. Vanderbilt nurse: safeguards were ‘overridden’ in medication error, prosecutors say. By Steven ... prompted CMS to threaten VUMC's ... with a CMS report. Every nurse’s nightmare. The Tennessean. For Vaught, however, there has been no such resolution. The report mentions that this nurse was in a “help all” position that didn’t have a job description or formal training. 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. 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]." 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. The event occurred on 12/26/17. “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 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. The nurse got the vecoronium out of the neuro ICU pyxis, where the patient was an inpatient. 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. Vanderbilt ex-nurse indicted on reckless homicide charge after deadly medication swap Vanderbilt death: Victim would forgive nurse who mixed up … Although the licensing division of the Tennessee Department of Health decided not to take disciplinary action, the criminal case continues. 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. January/February 2007. 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. “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. 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.” New research published in July's issue of Health Affairs finds wide variability in nurse staffing at U.S. nursing homes. The Just Culture Community News and Views. I just got done reading the 56 page CMS report and I have a lot more questions than when I started. Another Fatal Vecuronium Error! Across all types and sizes of facilities and all nurse levels, there is variations in the staffing of nursing home facilities. The error, which caused the death of an otherwise stable patient, has … Did you actually read the CMS report? CONTACT: Shannon McClendon, 301-628-5391 shannon.mcclendon@ana.org. 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. 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 bin was labelled as a paralytic that causes respiratory arrest. 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. Vanderbilt hastily submitted a corrective action plan, which CMS apparently deemed satisfactory; no details have been publicly released. Source document contributed to DocumentCloud by DocumentCloud Admin (McClatchy Washington Bureau). She's not sure how much she gave. Possible errors increased linearly with number of medications taken. 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 … 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. Brous contends that criminalizing the nurse … Most important is to look at what we can learn from the CMS report. 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. 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. There is even broad support against the case by the medical profession. Vanderbilt complied, and the CMS withdrew its funding threat. 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. 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. Marx D, Cassidy KM, eds. But that does not in any way negate the actions of this nurse. 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. 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. Vanderbilt Comments on Patient Error, CMS Corrective Action Plan. The CMS Statement of Deficiencies report also states Vanderbilt fired the nurse involved, then sent her to counseling. That explains how she had access to it. The CMS report, page 32, quotes a pharmacist as saying: "We rolled out EPIC, our new system for documentation last year in November [2017]." ... Vanderbilt complied, and the CMS withdrew its funding threat. Outcome Engenuity. She was also assigned an orientee that day to train. This nurse no details have been publicly released Health Affairs finds wide in... For Vaught, however, there has been no such resolution nurse at... 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