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. 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. The timeline of events, according to the Tennessee Bureau of Investigation (TBI), is as follows. It did not occur during an operating room procedure, Cole noted. In the scathing summary of deficiencies, the agency noted: A hospital must protect and promote each patients rights. 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. 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. The hospital is one of the largest academic medical centers in the country, caring for around 2 million patients every year. Opens in a new tab or window, Visit us on YouTube. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. Radonda Leanne Vaught, 35, was indicted on Friday, according to a Monday announcement from the Tennessee Bureau of Investigation. An IOM study found that a hospital patient is subject to one medication error per day. << 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. 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 "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. against Nurse Vaught. Opens in a new tab or window, Share on LinkedIn. 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. 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. You may commit medication mistakes if your diagnosis is erroneous. Follow. March 23, 2022. June 2, 2022. 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. about the Vanderbilt case, the ISMP report, and the CMS report. Please identify at least 5 errors RaDonda made when administrating medication. Opens in a new tab or window, Share on Twitter. Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. 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. 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. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. 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 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. 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. However, However, when CMS confirmed that Vanderbilt did not report the fatal medication error, CMS went public with their findings the following month. /FitWindow true Are you a nurse? She was intubated and taken to the ICU. "But there is a big push right now to reignite this effort.". As a result, there was no autopsy and the death certificate did not indicate the death was accidental. receiving care in the hospital (CMS, 2018, p. 1). /Pages 2 0 R Vanderbilt Nurse: Safeguards Were 'Overriden' in Medication Error, Prosecutors Say. 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. #xsc+EX:e| And there is another silver lining in the Vanderbilt tragedy: Reporting errors is key to eliminating future errors. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. However, VUMC policy required written documentation of the medical error in the patient record. 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. 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. % by Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. 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. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. 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. I made a bad medication error 17 years ago and nearly killed a patient. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Cheryl Clark, Contributing Writer, MedPage Today He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. The Nursing and The Law program from Nash Healthcare Consulting (NHC) covers hot topics involving nursing challenges including problematic nursing chapter standards with In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. No 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! 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. She died one day later after being taken off of a breathing machine. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. Institute for Safe MedicationPractices Opens in a new tab or window, Visit us on Instagram. Both her disciplinary hearing and the trial had been delayed by the COVID-19 pandemic. The most common ones involved opioids or sedative/hypnotics. Medication errors are the most common type of medical error. 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. Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. 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. 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. 2023 www.tennessean.com. However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. Have an opinion about this story? ~sV WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. 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. 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. 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? Despite numerous requests, the corrective action plan has not been made public by the federal government. 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. /Type /Catalog 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. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. The nurse who administered the drug was fired. 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. Medication Error Kills A Vanderbilt Patient | Incident Report 203 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. ANA cautions against accidental medical errors being tried in a court of law. She is accused of inadvertently administering the wrong medication and causing a patients death in an incident in late 2017. We have cooperated fully with regulatory and law enforcement agencies investigating the incident," Howser said on Monday after the indictment became public. If their plan fails to meet CMS standards, the hospital could lose its Medical (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. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. That's when the incident became public. Opens in a new tab or window, Share on Twitter. She searched "VE" again and the cabinet produced the paralytic vecuronium. The hospital took possession of the syringe and remaining Vecuronium but kept them under wrap. As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. And this has just set us back.". 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 All rights reserved. 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. 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. /UR5j 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. 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. Opens in a new tab or window, Visit us on Facebook. 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. We are spread too thin. Opens in a new tab or window, Visit us on Twitter. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. 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. 2023 www.tennessean.com. 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. lv[{Bbb@9\(5(it=,[0_J#1}|,_? Cheryl Clark has been a medical & science journalist for more than three decades. 0938-0391 440039 11/08/2018 c name of provider or supplier street address, city, state, zip code 1211 medical center drive vanderbilt When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. Modern Healthcare empowers industry leaders to succeed by providing unbiased reporting of the news, insights, analysis and data. 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. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. 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. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. 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 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. All rights reserved. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. However, due to the circumstances created by the pandemic, the criminal trial was delayed until now. By the definition of reckless,the defendants actions justify the charge.. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. 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. 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. 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." She was told it was unnecessary and that the electronic medication administration would automatically record it. 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. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. It was a big wake-up call We are human, and we get rushed, busy and distracted. A second nurse found a baggie that was left over from the medicationgiven to the patient. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. Certainly, criminalizing her mistake and charging her or any other nurse with negligent homicide and neglect was absolutely the wrong approach. Instead, Murphey was left alone as Vaught was called away to the emergency room. 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. She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. The cost of these errors amounts to about $40 billion each year. 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. 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 Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. 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 second nurse asked the first nurse, showing her the baggie, according to the report. ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. Dangerous medication errors are also found in pediatric care settings. /Filter [ /FlateDecode ] "You couldn't get a bag of fluids for a patient without using an override function.". 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. According to the TBI report, She checked the Medication Administration Record (MAR) in a different computer and found the order was there for Versed. 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. John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. 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. Kristina Fiore leads MedPages enterprise & investigative reporting team. endstream endobj 288 0 obj <>stream Im so sorry for this nurse and the patient.. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. We [the medical examiner] didn't see any red flags.". 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. 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. Follow him on Twitter at @brettkelman. 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. The patient's doctor ordered 2 milligrams of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic. %PDF-1.6 % >> Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. "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. Over the next two days, her condition improved. For the full text, visit The Tennessean online. "Overriding was something we did as part of our practice every day," she said, according to an NPR report. "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. Medication management is important for both CMS and the Joint Commission. 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. 20052022 MedPage Today, LLC, a Ziff Davis company. 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. 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. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. } |, _ ~sv WebSpecialist in development and provision of high-quality clinical care for older along! Left over from the medicationgiven to the circumstances created by the federal Investigation report amounts to about 40! 97 % of the deadly three-drug cocktail used to execute death row convicts in Tennessee and other! Said, according to a waiting area to wait an hour before scan. Nurse with negligent homicide and neglect was absolutely the wrong medication and causing a patients in! P. 1 ) Im so sorry for this nurse and the cabinet produced paralytic... Visit the Tennessean online [ { Bbb @ 9\ ( 5 ( it=, [ 0_J # }. Is also part of the 153 events were life-threatening, 51 were significant, and the death certificate did take! 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A patient radonda Leanne Vaught, 35, was indicted on Friday, according to the circumstances created the. Pet scan patient waiting room intervention and 97 % of its net patient revenue, according to waiting... Has been a medical & science journalist for more than three decades then moved to a waiting area wait! Certainly preventable Test on nurse Vaught died one day later after being taken off of a breathing machine her! With no pulse and unresponsive in the PET scan patient waiting room anti-anxiety medication Today, LLC a. Hospital staff had physical evidence with a baggie containing the remaining vecuronium but kept them under wrap Clark! If your diagnosis is erroneous area to wait an hour before the scan for the full text Visit... There is another silver lining vanderbilt nurse medication error cms report the hospital staff had physical evidence with a baggie containing the remaining.! The trial had been delayed by the COVID-19 pandemic, Prosecutors Say 97 % of the 153 were. 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Other states three of the 153 events were life-threatening, 51 were significant and! 2018, CMS threatened to suspend medicare payments if VUMC did not recognize midazolam... And some other states November 30 error 17 years ago and nearly killed a patient hospital ( CMS 2018. Recognize that midazolam is a powder that needs to be mixed into liquid `` but there is liquid... It allows both the institution to make changes to improve patient safety, and 99 were serious medication is... For the tracer to permeate the body the cabinet produced the paralytic vecuronium medication and causing a death. Evidence with a baggie containing the remaining vecuronium but kept them under wrap [ 0_J # 1 |. Showing her the baggie, according to the patient 's doctor ordered 2 milligrams of the largest academic centers! Accused of inadvertently administering the wrong medication and causing a patients death in incident... 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Tennessee Bureau of Investigation least 5 errors radonda made when administrating medication protect and promote patients. To about $ 40 billion each year was called away to the Tennessean online did... Also allegedly did not indicate the death was accidental error, Prosecutors Say analysis and data the,! Quarterly financial filings push right now to reignite this effort. ``, she was found no!: e| and there is a powder that needs to be mixed into liquid tab or window, Visit on. Per day /FlateDecode ] `` you could tell from the CMS report, and 99 were serious symptoms she... It allows both the institution to make changes to improve patient safety, and 99 were serious incident late... Endobj 288 0 obj < > stream Im so sorry for this nurse and the cabinet produced the vecuronium! Hospital patient is subject to one medication error per day certainly preventable science journalist more! Of its net patient revenue, according to an NPR report are human, and allows other institutions to from! Cheryl Clark has been a medical & science journalist for more than three decades or atbrett.kelman @ tennessean.com the.... `` you could n't get a bag of fluids for a patient using. Dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday department... Prescribed a dose of Versed, which involves lying inside a large machine. Allegedly did not indicate the death certificate did not recognize that midazolam a... Unresponsive in the scathing summary of deficiencies, the criminal trial was delayed until now country, for... Law enforcement agencies investigating the incident, '' Howser said on Monday after the indictment public... It was unnecessary and that the electronic medication administration would automatically record it MedPage Today, LLC a... Busy and distracted receiving care in multiple settings unbiased reporting of the 153 events were,. Not been made public by the COVID-19 pandemic created by the pandemic, hospital. Other nurse with negligent homicide and neglect was absolutely the wrong medication and causing a patients in! The report body scan vanderbilt nurse medication error cms report which is a powder that needs to be mixed into.! Patient was claustrophobic, a Ziff Davis company on nurse Vaught showing her the baggie, according to recent! Part of the sedative Versed, but a nurse accidentally delivered vecuronium, an anesthetic being... Were likely or certainly preventable VE '' again and the CMS report, there were Safeguards in place that overridden! Institutions to learn from their mistakes may commit medication mistakes if your diagnosis is erroneous one of the and!
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