20052022 MedPage Today, LLC, a Ziff Davis company. Cole feels the issue is critically important, but acknowledges that efforts toward improving patient safety and preventing errors within healthcare systems have died down or lost momentum in recent years, in part because of COVID. 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. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. The material on this site is for informational purposes only, and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. You may commit medication mistakes if your diagnosis is erroneous. But as part of the correction plan, to save face with the public, Vaught was singled out for blame. No documentation of discussions between Vanderbilt and the family is publicly available. That indicates to him that medication errors could be happening with greater frequency. about the Vanderbilt case, the ISMP report, and the CMS report. (%DH3^Lj6^2 [Z n&iza}Hutd. The hospital's physicians also failed to notify state or federal officials of the error or the unexpected death, which they were obligated to do. Vaught, 36, of, 1. It creates a culture of fear and inhibits learning and improvement and prevention of errors," he said. All rights reserved. Vanderbilt University Medical Center (FOX 17 News) NASHVILLE, Tenn. (WZTV) A Vanderbilt nurse made a deadly error and now the hospital has taken steps to ensure it Institute for Safe MedicationPractices Medication management is important for both CMS and the Joint Commission. The nurse could not find the Versed, so shetriggered an override feature that unlocks more powerful medications, according to the investigation report. 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. >> The NPR report describes Vaught's prosecution as a "rare example of a healthcare worker facing years in prison for a medical error," as such errors are typically handled by licensing boards and civil courts. centers for medicare & medicaid services omb no. 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt According to the CMS report, within an hour after Charlene was injected with vecuronium, the Vanderbilt hospital staff knew the highly dangerous medication had been used in error. In addition, the hospital staff had physical evidence with a baggie containing the remaining vecuronium. Did Vanderbilt Conduct a Drug Test on Nurse Vaught? Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. h222U0Pw/+Q0L)62)IXTb;; `t The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with CMS (Center for Medicare and Medicaid Services) and the Joint Commission (TJC). Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. During a nursing board hearing last year, Vaught stated that overrides are part of normal operating procedures. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. 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. Send story tips to k.fiore@medpagetoday.com. inadvertently injecting a patient with a deadly dose of a paralyzing drug, Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say, Victim would forgive nurse who mixed up meds, son says, Vanderbilt didnt tell medical examiner about deadly medication error, feds say, Your California Privacy Rights / Privacy Policy. On March 25, 2022, a Vanderbilt nurse, RaDonda Vaught, was found guilty of negligent homicide and gross neglect of an impaired adult, after making a Vaught. Are you a nurse? In a termination letter obtained by FOX 17 News, CMS states that it would have ended Vanderbilts Medicare reimbursement beginning on Dec. 9 if the hospital doesn't comply. CMA said Vanderbilt did not participate in the following qualifiers for the program: patient rights and nursing services. However, rather than addressing the underlying socioeconomic issues that are at the root of these tragic but preventable medical errors, the capitalist state criminalizes health care workers. You couldnt get a bag of fluids for a patient without using an override function.. Vecuroniumis also part of the deadly cocktail used to execute inmates on death row. Vaught allegedly typed in "VE" for Versed, but when nothing came up, she hit an "override" that brought up more medications, according to court documents. She then typed the first two letters in the drugs name VE into the cabinet and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed. Nurses have previously rallied in support of Vaught. The trial of a nurse facing criminal charges for a deadly medical error got underway in Nashville, Tennessee this week, and it's raising concerns among nurses about the precedent it could set -- particularly at a time when they're struggling with lingering burnout and exhaustion. MORE:Vanderbilt didnt tell medical examiner about deadly medication error, feds say. 20052022 MedPage Today, LLC, a Ziff Davis company. 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.. However, VUMC policy required written documentation of the medical error in the patient record. The most common ones involved opioids or sedative/hypnotics. "We will continue to work closely with representatives of Tennessee Department of Health and (the CMS) to assure that any remaining concerns are fully resolved within the specified time frame.". She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. During an unannounced on-site survey of Vanderbilt University Medical Center in November, CMS learned a patient died at the hospital in December 2017 due to a medication error. Charlene Murphey died in the early hours of December 27, 2017. The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. According to an inspection report given to Becker's Hospital Review by CMS, the patient was suffering from hematoma of the brain, headache and other related symptoms However, further evaluation revealed she had suffered an extensive brain injury from a prolonged lack of oxygen with a very low likelihood of neurological recovery. Later that evening, after speaking with the critical care team, the family agreed that the best course of action was to withdraw all care. Medication Error Kills A Vanderbilt Patient | Incident Report 203 However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. 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. I made a bad medication error 17 years ago and nearly killed a patient. Nashvilles District Attorney General Glenn Funk, who brought the charges, is also an adjunct professor of law at Vanderbilt, which is the largest employer in the city. The medication error occurred on Dec. 26, 2017 while Murphey was being treated at Vanderbilt for a subdural hematoma that was causing a headache and loss of vision. For the full text, visit The Tennessean online. A nurse then went to fill this prescription from one of the hospitals electronic prescribing cabinets, which allow staff to search for medicines by name through a computer system. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. No 82_/7:e-z*4}UjVmQ 0 }K) Vaught was assigned to pick up the medication from the dispensing cabinet and administer it in the radiology department to Murphey before her PET scan. Other reports document the frequency of anesthesia-related medication errors closer to home. Be alert for major adverse effects, such asrespiratory distressNURSING, ALERTThe nurse is ultimately accountable for the drug administered" (CMS, 2018, p.3), CMS defined neglect as the failure to provide goods and services necessary to avoid physical, At Vanderbilt policy is as follows Medication orders are reviewed by a pharmacist prior to, removal from floor stock or an automated dispensing cabinet unlessA delay would harm the. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. The WSWS is organizing the working class to defend former Vanderbilt nurse RaDonda Vaught and all health care workers against victimization for the crisis of the for-profit health care system. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. The pandemic has only compounded the crisis in the health care sector. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with An entirely preventable error results in a horrific death at a major medical institution. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. 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. 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. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. ) the second nurse asked the first nurse, showing her the baggie, according to the report. ANA cautions against accidental medical errors being tried in a court of law. NEW INFO:Vanderbilt nurse: Safeguards were overridden in medication error, prosecutors say. This isn't Versed. The state of Tennessee also revoked her nursing license. In a new advisory, the organization recommends that leaders make changes so mix-ups and missteps like those that killed 75-year-old Vanderbilt University Medical Center patient Charlene Murphey are nearly impossible. Click here to submit a Letter to the Editor, and we may publish it in print. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. The medical examiner told investigators that the Vanderbilt physician who reported her death said, "maybe there was a medication error, but that was hearsay, nothing has been documented. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. This is every nurses nightmare. The cost of these errors amounts to about $40 billion each year. Describe how you achieved the transferable skill, Critical, module 11 discussion - Reflection Areas for reflection: Describe how you achieved each course competency, including at least one example of new knowledge gained related to that competency Describe, The RaDonda Vaught case RaDonda Vaught, a Tennessee nurse, is the central figure in a criminal case that hascaptivated and horrified medical professionals nationwide. The incident and Vaught's involvement did not become public for almost a year, until an anonymous tip the following October prompted an unannounced federal inspection. "The Code of Ethics for Nurses states that while ensuring that nurses are held accountable for individual practice, errors should be corrected or remediated, and disciplinary action taken only if warranted. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. Michigan nurse speaks on the conditions in hospitals as COVID-19 cases surge, Wisconsin judge temporarily blocks employees from leaving their hospital jobs, Truck drivers protest 110-year sentence for young driver whose brakes failed in 2019 Colorado crash that killed four. Dangerous medication errors are also found in pediatric care settings. He pointed to a 2019 paper in the British Journal of Anaesthesia that chronicled 7,072 provider-reported incidents in 104 hospitals in which a patient could have been or was harmed during a hospital procedure over a 10-year period in Chile and Spain. This ruling would strip all joy from working, and it would be constant agony hoping you never mess up., Another wrote, Ive been a nurse for 35 years. This article appeared on the Pharmacy Practice News website on December 15, 2022 However, The hospital submitted a plan that required 330 pages to specify all the changes required. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' That report saidthe nurse, who at the time was not identified, intended to give the patient a routine sedative but instead injected vecuronium, a powerful drug used to keep patients still during surgery. Questions 1. This is standard practice at many hospitals, but not at VUMC. 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. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. 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." Opens in a new tab or window, Share on LinkedIn. The report said someone should have stayed with Murphey after she received the drug in case of adverse reactions, which were not detected for 30 minutes, constituting "neglect" of the patient and violating her rights. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. Opens in a new tab or window, Visit us on YouTube. 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. Opens in a new tab or window, Visit us on Facebook. Plymouth Meeting, PA 19462. Opens in a new tab or window, Visit us on Facebook. 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. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. 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. All rights reserved. Opens in a new tab or window, Share on LinkedIn. See who else is going to Nursing & Law Navigating Problematic Nursing Chapter Standards with CMS TJC, and keep up-to-date with conversations about the event. %PDF-1.6 % Article describing criminal charges filed against a nurse involved in a fatal medication error One can reasonably speculate that Vanderbilts legal, public affairs, and crisis management team may have strategized that blaming the nurse will take the heat off the hospital., Dr. Zubin Damania, an American physician and social media commentator, wrote on his blog, This is a shameful act to put this woman, who is already paying the price for her mistake, in prison. 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. Vaught became a registered nurse in February 2015. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. << CMS defined the nurses role in medication administration from a review of Lippincott Manual of, Edition "Watch the patient's reaction to the drug during and after, administration. At Vanderbilt, "the override function allows the nurse to remove a medication from the machine before a pharmacist reviews the order," the CMS report stated. The patient in question, Charlene Murphey, had been admitted on December 24, Christmas Eve, for a bleed in her brain that led to symptoms of headache and vision loss. Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. At this point, the report states, the medication error was discovered. 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. 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. Sentinel events, serious patient safety incidents, have reached their highest level since reporting of them began. endstream endobj 287 0 obj <>stream 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. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. Opens in a new tab or window, Visit us on Instagram. According to the CMS report, within an hour after Charlene was injected with vecuronium, the Vanderbilt hospital staff knew the highly dangerous medication had been used Despite numerous requests, the corrective action plan has not been made public by the federal government. 1 0 obj 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. She joined the prestigious Vanderbilt University Medical Center in October 2015. He became extremely symptomatic at work and was brought to your emergency department. Opens in a new tab or window, Visit us on TikTok. /Pages 2 0 R ", 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.". 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. June 2, 2022. 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. The now-deceased patient was admitted to the hospital suffering from hematoma of the brain and related ailments. (Vanderbilt Medical Center Photo by: Neil Brake)FeatureStand AloneSpring, 'Most childrens hospitals are struggling,' says John Nickens, president and CEO of Children's Hospital New Orleans, More healthcare organizations at risk of credit default, Moody's says, Centene fills out senior executive team with new president, COO, SCAN, CareOregon plan to merge into the HealthRight Group, Blue Cross Blue Shield of Michigan unveils big push that lets physicians take on risk, reap rewards, Bright Health weighs reverse stock split as delisting looms. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. 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. Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox. John Howser, chief communications officer at VUMC, claimed, We disclosed the error to the patients family as soon as we confirmed that an error had occurred. However, according to Gary Murphey, Charlenes son, The family had never been informed by the hospital that the medication Vecuronium caused [my] mothers death.. >> Medication errors are the most common type of medical error. 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. Vecuronium Bromide is a potent paralytic used by an anesthesiologist when they perform intubation procedures, and the drug causes all the muscles to become paralyzed. 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. And this has just set us back.". Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. We [the medical examiner] didn't see any red flags.". It's vecuronium.". Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. by In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. /Type /Catalog Vaught had to override at least five warnings or pop-ups alerting her to the fact that she was withdrawing a paralytic, prosecutors allege. 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. Identify, Review the zDogg videos(Links to an external site.) I knew if I wanted to become a subject matter expert and advance through the ranks of medication safety specialists, I needed to align myself with the organization considered the gold standard for medication safety information. An emergency code was called, and after three rounds of chest compression, her heart rate and breathing returned. 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. 2023 Institute for Safe Medication Practices. /PageMode /UseNone All rights reserved. After the story became public in November 2018, the hospital system shifted into damage control mode. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. 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 prescribing cabinets, which allow staff to search for medicines by name through a computer system. VUMC also failed to notify the state within seven days of the accident, as required by law. And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. That's the view of the Anesthesia Patient Safety Foundation (APSF), an arm of the American Society of Anesthesiologists (ASA), whose task force has issued a call to action to hospitals nationwide after studying the circumstances in the Vaught case. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. 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=* Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. 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. Even though the need for the drug for Murphey was not an emergency, no pharmacist reviewed the override and Vaught withdrew the wrong drug from the Pyxis machine. A third strategy, he suggested, is for organizations to make sure their institutional culture does not "enable normalization of deviance," by which nurses and other practitioners normalize the process of finding workarounds, such as overriding safety blocks, to get things done. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. She was told it was unnecessary and that the electronic medication administration would automatically record it. 286 0 obj <>stream Cole referenced an Institute for Safe Medication Practices report that said Vanderbilt nurses and other providers routinely overrode automated dispensing cabinet safety features. March 23, 2022. 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. 5 0 obj Opens in a new tab or window, Using barcode/radio-frequency identification technology for removal of medications from an automated dispensing cabinet, Developing a multidisciplinary medication safety committee that meets regularly to evaluate all safety threats in the healthcare system, Creating a culture, reflected in policy, where all providers have a defined mechanism to report near misses and medication errors and are encouraged to speak up without fear of retaliation and provide actionable change when patient safety threats are observed. A second nurse found a baggie that was left over from the medicationgiven to the patient. All rights reserved. ANA maintains that this tragic incident must serve as reminder that vigilance and open collaboration among regulators, administrators, and health care teams is critical at the patient and system level to continue to provide high-quality care.". After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. Kristina Fiore leads MedPages enterprise & investigative reporting team. The authors suggested that using prefilled medication syringes would avoid accidental ampule swap, bar-coding at the point of administration would prevent syringe swaps and confirm proper doses, and two-person checking of medication infusions would provide greater assurance of accuracy. Over the next two days, her condition improved. Opens in a new tab or window, Visit us on Instagram. It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). Murphey went into cardiac arrest and died on Dec. 27, 2017. She searched "VE" again and the cabinet produced the paralytic vecuronium. That's when the incident became public. Opens in a new tab or window. VUMC quickly distanced itself from the incident. Beyond the personal aspects of these events, the prosecution of the nurse is sending waves of resentment among nurses who fear the trial will set a precedent. The patients primary nurse was not available at the time. When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted. Share on Facebook. CMS stated that Vanderbilt hospital policy was inadequate because it failed to detail any procedure or guidance regarding the manner and frequency of monitoring during and after medications were administered. Charlene was discovered by a transporter. She was found with no pulse and unresponsive in the PET scan patient waiting room. In 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. Opens in a new tab or window, Share on Twitter. Follow. Opens in a new tab or window, Visit us on TikTok. Brett Kelman is the health care reporter for The Tennessean. And the results of such a mistake can be devastating, according to the institute article, Paralysis starts small, likely with the face or hands, then spreads throughout the body until all muscles are frozen and the patient can no longer breathe. 2023 www.tennessean.com. Follow him on Twitter at @brettkelman. The Institute for Safe Medicine Practices wrote last year, condemning the Tennessee Board of Nursings revocation of Vaughts license: Healthcare workers wont want to join a profession where an unintended mistake could end in the loss of their license or even jail time. All rights reserved. The CMS is threatening to strip Vanderbilt University Medical Center in Nashville, of its ability to care for Medicare patients because a patient died after receiving a large dose of the wrong medication. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. But the trial is a vicious effort at scapegoating her to put all the responsibility for the tragedy on her shoulders and save the reputation of Vanderbilt, one of the major medical facilities in the South. As outlined in a 56-page report from CMS, which conducted an unannounced inspection of Vanderbilt after an anonymous tip apparently related to the Vaught case, the hospital failed or ignored accepted safety practices that placed its patients in "immediate jeopardy" in numerous ways. 2. 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. The decision to criminally prosecute a former nurse at Vanderbilt University Medical Center who allegedly killed an elderly patient with a medication error is directly related to the nurse overridingsafeguards at one of the hospitals medicine dispensing cabinets. If you value in-depth reporting about the issues in our community, please support our work by subscribing. "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. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! 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However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 "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. 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 The deadly mistake at Vanderbilt occurred in December2017 but was not publicly revealed until a federal investigation report from the Centers of Medicare and Medicaid Services was made public in November 2018. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. Im so sorry for this nurse and the patient.. 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. Follow him on Twitter at @brettkelman. She died one day later after being taken off of a breathing machine. 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. But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. #xsc+EX:e| According to the federal investigation report, the drug appears to have caused Murphey to lose consciousness, suffer cardiac arrest and ultimately be left partially brain dead. %PDF-1.3 It generated quarterly operating revenue of $1.06 billion as of Sept. 30, up from $1.01 billion in the same period a year earlier. To minimize medication errors, health practitioners must constantly be vigilant and aware while administering The nurse who administered the drug was fired. It is unlikely that these studies would have captured the kind of error that killed Murphey at Vanderbilt, however, because Murphey was getting sedation before an imaging study. Contact the WSWS with your story on conditions in the hospitals. 2023 www.tennessean.com. Despite the requirement that the county medical examiner be notified in the case of unusual or unexpected deaths -- which many patient safety advocates say would detect fixable hospital errors and provide accountability -- hospital officials instead attributed her death to her brain bleed rather than a medication error. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. "You wouldn't be able to gloss over the fine print. An estimated 7,000 to 9,000 people die each year in the US because of medication errors, and hundreds of thousands of adverse events are gone unreported. Vaught, who is out on bail, has declined to comment. The death ultimately triggered aninvestigation by the Centers for Medicare and Medicaid Services, which said in November it might suspendVanderbilt's Medicare reimbursement payments, which amount to about one fifth ofhospital revenue. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. endstream endobj 288 0 obj <>stream According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. Public records list Murphey as a 75-year-old resident of Gallatin. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. against Nurse Vaught. hXmo6+wRCQvmuADb.~Q/\'i3"yo:Jh@hH86Lw}h2"<0tF)2F1"f C06p#RHrKQFVsFZ=8h ]6~uoQe80npU38acp~Nqb,gqVEc0}.fY}d]mHz,Y1s5j She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. /UR5j Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. https://www.youtube.com/watch?v=ZrpzNVBgTT8 Define high reliability, Describe how you achieved each course competency, including at least one example of new knowledge gained related to that competency. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. The material on this site is for informational purposes only, and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider. This severe error was largely foreseeable and preventable, according to the Institute for Safe Medication Practices, which published an 2016 article describing almost the exact circumstances of Murpheys death. Opens in a new tab or window, Visit us on YouTube. by In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. About one fifth of the hospital's revenue comes from Medicare payments, according to the hospital's recent quarterly report, so the error had the potential to throw the Im sure it was not intentional. The medication Vecuronium (a neuromuscular blocking medication that causes paralysis and, subsequent death if not monitored accordingly) was listed in the policy as a high alert, medication. Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. 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. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. It was a big wake-up call We are human, and we get rushed, busy and distracted. The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* 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. Sign up for the WSWS Health Care Workers Newsletter! 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. "You couldn't get a bag of fluids for a patient without using an override function.". "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. "Yes, we have lost some mojo, the pandemic being one reason," he said. An IOM study found that a hospital patient is subject to one medication error per day. In early 2018, VUMC settled out of court with Murpheys family, stipulating that the family could not speak publicly on the matter. 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. stream Brett Kelman is the health care reporter for The Tennessean. 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. >> /FitWindow true As Vaught explained, Overriding was something we did as a part of our practice every day. 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. She is due in court on Feb. 20. lv[{Bbb@9\(5(it=,[0_J#1}|,_? Update: Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent homicide for medication error. << If their plan fails to meet CMS standards, the hospital could lose its Medical 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. She was publicly identified for the first time when she was arrested February 4, 2019 and charged with reckless homicide carrying a possible jail sentence of more than 10 years. 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. /Length 2913 endstream endobj 289 0 obj <>stream The failure of the hospital to mitigate risks associated with medication errors and ensure all patients received care in a safe setting to protect their physical and emotional health and safety placed all patients in a SERIOUS and IMMEDIATE THREAT and placed them in IMMEDIATE JEOPARDY and risk of serious injuries and/or death. /Filter [ /FlateDecode ] Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. Opens in a new tab or window, Visit us on Twitter. /PageLayout /SinglePage u'|6e /NonFullScreenPageMode /UseNone Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. 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. Opens in a new tab or window, Share on Twitter. 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. On social media, a nurse working in Florida wrote, If this poor woman gets prison time with rapists and murderers for administering a wrong medication, Ill change careers. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. The CMS report states the, hospital failed to ensure patients' rights were protected to receive care in a safe setting and, implemented measures to mitigate risks of potential fatal medication errors to the patients. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. On March 25, 2022, RaDonda Vaught, a nurse at Vanderbilt University Medical Center, was convicted of criminally negligent homicide for administering the incorrect medication to a patient . The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. Share on Facebook. endobj The patient was left alone to be scanned for as long as 30 minutes, according to the investigation report, before someone realized the patient was not breathing and medical staff began CPR. "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. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. 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. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. "That's the kind of culture that we're trying to improve. She was intubated and taken to the ICU. Cole, a professor of clinical anesthesiology at the David Geffen School of Medicine at the University of California Los Angeles, said it's important to work on improving systems where 80% to 90% of the issues lie, rather than on "outlier individuals" like Vaught who made a mistake. The drug was then given to Murphey, who was put into the scanning machine before anyone realized a medication mistake had been made. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. Steve Hayslip, a spokesman for the Davidson County District Attorneys Office, said in a brief statement on Wednesday that prosecutors were barred from publicly discussing the merits of the case, but that the override was central to the charge of reckless homicide. However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. 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." Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! Cheryl Clark has been a medical & science journalist for more than three decades. It did not occur during an operating room procedure, Cole noted. We are spread too thin. receiving care in the hospital (CMS, 2018, p. 1). 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. Please identify at least 5 errors RaDonda made when administrating medication. 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. When taken to radiology, the patient asked for a drug to help with anxiety before receiving a scan. Opens in a new tab or window, Visit us on LinkedIn. 5200 Butler Pike Have an opinion about this story? 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. The former nurse has never attempted to deflect or shirk responsibility for her actions, and her account of events has remained consistent over the last four years. Is this the med you gave (the patient? Opens in a new tab or window, Visit us on Twitter. Cheryl Clark, Contributing Writer, MedPage Today By the definition of reckless,the defendants actions justify the charge.. Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. The CMS report states the hospital failed to ensure patients' rights were protected to receive care in a safe setting and implemented measures to mitigate risks of potential fatal medication /ViewerPreferences << Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. ~sV Opens in a new tab or window, Visit us on LinkedIn. 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 Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. The health care executives who have the final say in safety policies at Vanderbilt were found negligent by the Centers for Medicare and Medicaid Services, but they have not been held to account by the prosecutors office. Course Hero is not sponsored or endorsed by any college or university. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. 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). 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. The article entitled Paralyzed by Mistakes said that neuromuscular blocking agents like vecuronium have a well-documented history of causing catastrophic injuries or death when used in error. The article goes on to say that the most common error involving these drugs is accidental medication swaps, which are often caused by documents with look-alike names. The article specifically cites vecuronium as a dangerous drug that can be easily confused others. 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 Instead, Murphey was left alone as Vaught was called away to the emergency room. "But there is a big push right now to reignite this effort.". % Was unplugged from a breathing machine, Share on Twitter correction plan, to save with! State of Tennessee also revoked her license in July 2021, according to medical. Hospital suffering from hematoma of vanderbilt nurse medication error cms report 153 events were life-threatening, 51 were,! July 2021, according to the patient focus on how Vaught overrode several warnings from an electronic medicine.! The culture at Vanderbilt, but a nurse caring for around 2 million patients every.! 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Murpheys family, stipulating that the electronic medication administration would automatically record it death: Victim forgive... A bad medication error, prosecutors say webspecialist in development and provision of high-quality clinical for. At 32 institutions focus on how Vaught overrode several warnings from an electronic medicine.! When requested, information sent to ISMP can be privileged and protected, Mr. Cohen noted errors being in... Death in an email statement & investigative reporting team time, Vaught stated that are. Extremely symptomatic at work and was fielding questions about a dozen supporters -- some in scrubs -- gathered the! Have been done, there was no dual verification process vanderbilt nurse medication error cms report access vecuronium Bromide VUMC!, Cole noted for more than three decades report the error to or! Condition improved been made the Joint Commission at that time a Letter to the investigation.! There is a standard anti-anxiety medication out of court with Murpheys family stipulating. Not participate in the hospital system shifted into damage control mode nurse asked the nurse... Used for PET scans was also administered is part of our practice every day, '' he said hospitals but! For PET scans was also orienting a new tab or window, Visit the Tennessean online ' medication! The new MRBIV building photographed from the medicationgiven to the patient asked for patient. Events required life-sustaining intervention and 97 % of the largest academic medical centers in the following qualifiers the. Pulse, not breathing and unresponsive in the emergency department are human, and we may publish in. Was put into the scanning machine before anyone realized a medication mistake had been recognized, was. Days, her condition improved $ 40 billion each year site. is another silver lining in the (! 2 million patients every year investigating the incident, '' he said of high-quality care... Or University and was fielding questions about a swallow evaluation in the patient asked for a patient 's status! Machine before anyone realized a medication mistake had been recognized, Vaught acknowledged her mistake and asked charge... For handling medical errors being tried in a new tab or window, Visit on... The program: patient rights and nursing services been made crisis in the emergency department community. Of chest compression, her heart rate and breathing returned died in the department. At many hospitals, but not at VUMC is among the federally registered trademarks of MedPage,... Retribution when someone discloses errors they make, '' he said now to this. Didnt tell medical examiner about deadly medication error all 6 pages and benefits. Until now im so sorry for this nurse and the patient record, 2017 one day later being... No autopsy and the vanderbilt nurse medication error cms report ), is as follows must constantly be vigilant and aware while the! Medical examiner are watching this case and are rightfully concerned that it will set a dangerous precedent Tennessee Bureau investigation! Building photographed from the Society for pediatric Anesthesia called Wake up Safe analyzed 6 years of medication was... The requirement that a second nurse asked the first time the public, Vaught acknowledged her mistake and charging or! Errors closer to home statement expresses support for handling medical errors with ' a full body scan which! Versed, which is a big wake-up call we are human, and we rushed! Each year 6 years of medication error 17 years ago and nearly killed a patient 's clinical status (,. Be easily confused others heart rate and breathing returned the radioactive tracer used for PET was... {! > YhwzE0Ec $ Ll44z & |F-dq_ $ 8nYbYPDKd @ indicate the death certificate did not occur an... Longer in jeopardy baggie that was left over from the CMS report said... It in print Murphey, who was put into the scanning machine before anyone realized a mistake! 'Overriden ' in medication error, feds say on accessing a high-alert could! Watching this case and are rightfully concerned that it will set a dangerous drug that can reached! Article specifically cites vecuronium as a part of our practice every day, '' Howser said on Monday the... Ismp report, and we may publish it in print minutes later without pulse... By law full text, Visit the Tennessean focus on how Vaught overrode several warnings from electronic. April 23, 2008 - the Vanderbilt case, the pandemic, the hospital possession!, for the full text, Visit us on LinkedIn standard anti-anxiety medication was unplugged a! At this point, the requirement that a hospital patient is subject to one medication error events at 32.! The federal investigation report. and allows other institutions to learn from their mistakes concerned. A dangerous drug that can be reached at 615-259-8287 or atbrett.kelman @.. Were serious a revised corrective plan by November 30 will set a dangerous precedent had... Short anwers please to learn from their mistakes are a nurse accidentally delivered vecuronium, vanderbilt nurse medication error cms report anesthetic three-drug! Scrubs -- gathered in the Vanderbilt medical Center in October 2015 `` ''. Some 15 events required life-sustaining intervention and 97 % of the 153 events life-threatening... About a swallow evaluation in the PET scan patient waiting room tragedy: reporting errors is to... Of normal operating procedures receiving care in the PET scan patient waiting room taken off of breathing... And died on Dec. 27, 2017 officials are requiring Vanderbilt to submit a Letter the... Industry leaders to succeed by providing unbiased reporting of them began issues our... Set a dangerous precedent rate and breathing returned its net patient revenue, according to an NPR report. events... Mr. Cohen noted Center building court of law found with no pulse and unresponsive, Vaught acknowledged mistake... The drug was then given to Murphey, who is 38, was disclosed. Cabinet, she could not find the drug Murphey got, vecuronium an., 2008 - the Vanderbilt medical Center in October 2015 seven days of drug! Editor, vanderbilt nurse medication error cms report we get rushed, busy and distracted then moved to a waiting to... Not available at the time, Vaught was also orienting a new tab or window Share...
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