Despite the doctors 2 mg prescription, the nurse injected the patient with 10 mg of vecuronium, a dose which caused the patient to go into cardiac arrest, suffer partial brain death, and later die. Washington, DC: American Pharmacists Association; 2007:43-51. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. Inside the baggie was a vial with a few drops of clear liquid remaining in the vial. Nurse Vaught went back into the PET scan area and saw that the patient was intubated and had regained a heartbeat. Timeline of Events 12/26/2017 Nurse Vaught mistakenly administered vecuronium (brand name Norcuron) instead of the prescribed Versed to a 75-year-old patient, Charlene Murphey, prior to a PET scan. She died hours later, on Dec. 27, 2017, when she was unplugged from a breathing machine. At Vanderbilt, our patients' safety comes first. 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 tipster reported Nurse Vaught was orienting a new registered nurse when the patients nurse asked Nurse Vaught to give Versed to the patient. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. It is our moral imperative to change our current culture of abandonment, isolation, and punishment of second victims to a culture that provides accessible and effective support for these wounded healers.4 This support must begin the moment an event with the potential for causing emotional distress is discovered, and must extend for as long as deemed necessary.6 As an industry, we also need to facilitate the receptiveness of second victims to accept this support through widespread understanding and recognition of the enormous emotional toll second victims endure after involvement in a harmful event. ", "Transparent, just, and timely reporting mechanisms of medical errors without the fear of criminalization preserve safe patient care environments. Copyright 2023 Becker's Healthcare. Then he sued Trump and won. Radonda Vaught.Image via: Tennessee Bureau of Investigation. Not too long ago, we kept secrets about medical errors, trying in vain to maintain an image of perfection in healthcare. 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. After receiving information from Vanderbilt the Department conducted an investigation which was reviewed by the Departments nursing consultant and staff attorney. 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. Terry Bosen, Vanderbilt's pharmacy medication safety officer, testified that the hospital had some technical problems with medication cabinets in 2017 but that they were resolved weeks before . 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. Since there was no documentation and he/she said it was just hearsay, we didn't see any red flags". Additionally, the Vanderbilt doctor who reported the death to the medical examiner told investigators that they could not remember if they had mentioned the error. Send story tips to k.fiore@medpagetoday.com. It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. She practiced as a cardiac care nurse for several years before a chance opportunity to audit a graduate course in health care law and ethics changed her career path. Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent Certified Registered Nurse Anesthetist (CRNA). Share on Facebook. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. You couldnt get a bag of fluids for a patient without using an override function.37 Nurse Vaught testified that she allowed herself to become complacent and distracted while using the medication cabinet and did not double-check which drug she had withdrawn despite multiple opportunities. "You couldn't get a bag of fluids for a patient without using an override function.". In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. Since not all material facts in this case were covered by the media, a more thorough discussion is provided below. Court records state that Vaught would have had to look directly at a warning on the cap, saying WARNING: PARALYZING AGENT before injecting the drug. The second victims of errors have often suffered in silence. Michael R. Cohen, RPh, MS, FASHP. During a separate interview with federal officials, a medical examiners official said Vanderbilt should have informed himabout any error involving a paralyzing medicine. (A Vanderbilt doctor) stated maybe there was a medication error, but that was hearsay, nothing has been documented. In the last month, Kinnard Law Partner Randall L. Kinnard served as a featured speaker for legal seminars hosted by state trial Kinnard Law is pleased to announce that five of our firms attorneys have been named to the latest edition of The Best Lawyers in To schedule a detailed consultation with one of our Nashville personal injury lawyers, contact our office today. (The patient) got such a small dose, and he/she was anxious about the test, so we cant say it contributed to his/her demise.. What can we learn?CMS report and more here: http://zdoggmd.com/inci. The nurse, Kimberly, 50, committed suicide on April 3, 2011, just 7 months after making a mathematical error that led to an overdose of calcium chloride and the subsequent death of a critically ill infant. The patients primary care asked Nurse Vaught to go to the Radiology PET scanning room and administer Versed to the patient because she was not able to tolerate the PET scan procedure. The baggie contained the following:31 Clear zip lock baggie with an orange biohazard label had Versed 1 mg 2 mg PET 1251 handwritten in pink colored marker on it. A A The moment nurse RaDonda Vaught realized she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. The hospitals failures to mitigate risks following the incident, the CMS report says, is a sign of their failure to ensure competent care and the safety of all patients, and puts patients at immediate risk of serious injuries or death. But, too often, we remain silent and abandon the second victims of errorsour wounded healers4in their time of greatest need. Researchers in Pittsburgh found that an AI tool outperformed the three most common practices for analyzing ECGs of patients being treated for chest pain, reclassifying one of every three patients. There was no override verified by pharmacy and there was no documentation by Nurse Vaught that she administered vecuronium.5 At some time after the incident the family was told of a possible medication error.6A physicians note at 3:45 pm on 12/26/20177 indicates a code was called in the PET scan area. Today, we may be making headway with improved reporting and transparency of medical errors. "It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override.". That's when the incident became public. This doctor got political. Now he's out of a job. Nurse Vaught also admitted that she was distracted by talking to the orientee about a swallow test they were going to do. 20052022 MedPage Today, LLC, a Ziff Davis company. Now he's out of a job. Some of these codes will be available for use as early as July 1. We can also provide these victims with a sense of community, rather than isolation, by putting them in contact with other second (and third) victims who have been through similar experiences. ", Related: How DeKalb Medical Fixed Drug Safety Problems After Fatal Error, The statement, which specifically mentions Vaught's case, expresses support for handling medical errors with "a full and confidential peer review process.". "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. According to the investigative report, Nurse Vaught could not remember the reason she gave for the override. The most common ones involved opioids or sedative/hypnotics. Although the hospital has claimed it took appropriate action by terminating the nurse and disclosing the error to the patients family, regulators said the hospital failed to report the incident to the Tennessee Department of Health as required by law. February 20, 2019. On December 26, 2017, she was working as a help all nurse for the Neuro ICU, step down and the 6th floor nursing units.1 At that time Charlene Murphey, a 75-year woman with a subdural hematoma was a patient in the Neuro ICU. Opens in a new tab or window, Visit us on LinkedIn. Sharing the load. However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. As a testament to her longstanding compassionate and competent nursing care, many patients and families who received care from Kimberly attended her memorial service to honor her. Second victim rapid-response team. ANA Criticizes 'Criminalization of Medical Errors' as Vanderbilt Nurse The Institute for Healthcare Improvement (IHI) offers a white paper on Respectful Management of Serious Clinical Adverse Events.7 This is a comprehensive resource for responding to harmful patient events, which includes supportive actions for the second victims of errors. Steven Porter is an associate content manager and Strategy editor for HealthLeaders, a Simplify Compliance brand. This led the medical examiners office to decline to investigate because staff believed the patient died a natural death that was outside their investigatory jurisdiction. 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. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. Their website provides an extensive set of Tools for Building a Clinician and Staff Support Program. She was also found guilty of gross neglect of an impaired adult in a case that has fixed the attention of patient . Brett Kelman is the health care reporter for The Tennessean. The second victims of errors have the right to be treated with respect, to participate in the process of learning from the error, to be held accountable in a fair and just culture, not to be abandoned by the healthcare organization, and to be supported by their peers and organizational leaders.2 We need to take care of the patients and families that are harmed by medical errors; but we also need to take care of the practitioners involved in the errors, especially when they meant to do good and now find themselves in a situation where a patient has been harmed by their unintended actions.2 This is not a new issue in healthcare, but one that has taken a back seat to others. Administration of midazolam (generic 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 which may lead to hypoxia and/or cardiac arrest." But according to media reports, this and countless other efforts produced no job offers, increasing her isolation, despair, and depression. Follow. reconstitute with bacteriostatic water. The vial had a red top that said WARNING: PARALYZING AGENT. There was a 10 ml syringe labeled Normal Saline with a capped needle attached, with 1.5 ml of a clear liquid remaining in it and caped with a white cap with no needle. 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. The failure of the hospital to ensure all nurses "The failure of the hospital to ensure all nurses followed medication administration policies and procedures resulted in a fatal medication error and placed all patients in a serious and immediate threat to their health and safety and placed them in immediate jeopardy for risk of serious injuries and/or death," states the inspection report. Serious errors also result in competent practitioners losing their licenses or leaving the profession.3. 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.