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