I made a bad medication error 17 years ago and nearly killed a patient. According to the Tennessean, about a dozen supporters -- some in scrubs -- gathered in the courtroom during opening arguments on Tuesday. endstream endobj 287 0 obj <>stream >> 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. Charlene Murphey died in the early hours of December 27, 2017. Nurses are watching this case and are rightfully concerned that it will set a dangerous precedent. endstream endobj 289 0 obj <>stream Share on Facebook. She died one day later after being taken off of a breathing machine. 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. 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. Besides the standard of care checks that should have been done, there was no dual verification process to access Vecuronium Bromide at VUMC. Opens in a new tab or window, Share on Twitter. 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." Murphey wastaken to Vanderbilts radiology department to receive a full body scan, which involves lying inside a large tube-like machine. 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.. It allows both the institution to make changes to improve patient safety, and allows other institutions to learn from their mistakes. 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 nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. 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. This isn't Versed. receiving care in the hospital (CMS, 2018, p. 1). 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. Of 3,671 medication administrations involved, 193 (5.3%) were medication errors or adverse drug events, and 153 of those 193 events were preventable. Three of the 153 events were life-threatening, 51 were significant, and 99 were serious. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. Medpage Today is among the federally registered trademarks of MedPage Today, LLC and may not be used by third parties without explicit permission. Course Hero is not sponsored or endorsed by any college or university. 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. 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. "You wouldn't be able to gloss over the fine print. 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. 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. /ViewerPreferences << "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. April 23, 2008 - The Vanderbilt Medical Center main hospital and the new MRBIV building photographed from the new imaging center building. After the medication error had been recognized, Vaught acknowledged her mistake and asked the charge nurse if she should document what had happened. Nurses have previously rallied in support of Vaught. "We should celebrate error reporting rather than have retribution when someone discloses errors they make," he said. Medication Error Kills A Vanderbilt Patient | Incident Report 203 "Yes, we have lost some mojo, the pandemic being one reason," he said. 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. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. It did not occur during an operating room procedure, Cole noted. 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. Vaught, who is 38, was indicted in 2019 on two charges, reckless homicide and impaired adult abuse. "I don't know too much about the culture at Vanderbilt, but it doesn't help to blame individuals. Despite numerous requests, the corrective action plan has not been made public by the federal government. 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. She was discovered 30 minutes later without a pulse, not breathing and unresponsive. 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.". You couldnt get a bag of fluids for a patient without using an override function.. Opens in a new tab or window, Visit us on YouTube. The CMS report also said the name of the drug Murphey got, vecuronium, was not disclosed to the medical examiner. 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. 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). >> However, VUMC policy required written documentation of the medical error in the patient record. /PageLayout /SinglePage Questions 1. %PDF-1.6 % But neither the prosecutor nor the Tennessee Board of Licensing Health Care has taken any action against the health system. Had VUMC implemented safety measures commonplace at other health care facilities, the event could have been avoided. 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. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' This is standard practice at many hospitals, but not at VUMC. As a result, there was no autopsy and the death certificate did not indicate the death was accidental. However, the hospital didn't report the error to state or federal officials or to the Joint Commission at that time. /NonFullScreenPageMode /UseNone Use the form at the end of this article to sign up for the WSWS Health Care Workers Newsletter. 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. Vaught was fired from Vanderbilt University Medical Center in early January 2018, according to the CMS investigation. >VS"8uI,~< '' .@Nj,JeM}qHL+VgU~c: `Wu$,Kj,>t. Opens in a new tab or window, Visit us on Twitter. 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 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 On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. "That includes providing background information about the event itself, along with physical evidence, requested health records information and other documents.. All rights reserved. (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. VUMC quickly distanced itself from the incident. However, the CMS said that Vanderbilt failed to report the incident to the Tennessee Department of Health, as they are required to do. In some states, it is part of the three-drug cocktail used to carry out executions by lethal injection. The TBI announcement also identified the deceased patient, Charlene Murphey, for the first time. At the time, Vaught was also orienting a new employee and was fielding questions about a swallow evaluation in the emergency department. We are spread too thin. The Centers for Medicare and Medicaid Services (CMS) conducted an inspection at Vanderbilt and issued a Statement of Deficiencies concerning the patient death. Later that moth, CMS threatened to suspend Medicare payments if VUMC did not take immediate action to prevent similar future errors. The hospital submitted a plan that required 330 pages to specify all the changes required. Opens in a new tab or window, Visit us on Instagram. Contact the WSWS with your story on conditions in the hospitals. Brett Kelman is the health care reporter for The Tennessean. 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. Institute for Safe MedicationPractices 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. 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. 5200 Butler Pike It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. 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. 286 0 obj <>stream At Vanderbilt, the mistake caused Murphey to suffer cardiac arrest and brain death. 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Opens in a new tab or window, Visit us on TikTok. 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." 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. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. 0nWzxHl->I@0Ie.}P/\B-.{!> YhwzE0Ec$Ll44z&|F-dq_$8nYbYPDKd@! As you could tell from the CMS report, there were safeguards in place that were overridden, Hayslipsaid in an email statement. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. After Vaught gave Murphey the Vecuronium Bromide, the radioactive tracer used for PET scans was also administered. Sentinel events, serious patient safety incidents, have reached their highest level since reporting of them began. 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. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 Identify, Review the zDogg videos(Links to an external site.) 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. 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. 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. 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. stream "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. 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. Public records list Murphey as a 75-year-old resident of Gallatin. 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. If their plan fails to meet CMS standards, the hospital could lose its Medical She also allegedly did not recognize that midazolam is a liquid, while vecuronium is a powder that needs to be mixed into liquid. However, 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. Article describing criminal charges filed against a nurse involved in a fatal medication error 2023 www.tennessean.com. endobj Additionally, the requirement that a second nurse sign off on accessing a high-alert medication could have added redundancy to the safety measures. 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. 2. 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. Send story tips to k.fiore@medpagetoday.com. You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. She searched "VE" again and the cabinet produced the paralytic vecuronium. 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 In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. Murphey was then moved to a waiting area to wait an hour before the scan for the tracer to permeate the body. At this point, the report states, the medication error was discovered. 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. Other reports document the frequency of anesthesia-related medication errors closer to home. /UR5j VUMC also failed to notify the state within seven days of the accident, as required by law. Massachusetts General Hospital researchers reviewed 277 operations over a 7-month period between 2013 and 2014. by ", "ANA believes that the criminalization of medical errors could have a chilling effect on reporting and process improvement," the statement said. "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. ", 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.". CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. 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. Despite these symptoms, she was alert, awake and in improving condition, according to the federal investigation report. 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. When she attempted to withdraw Versed from the automatic medication dispensing cabinet, she could not find the drug listed in the patients profile. 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. But as part of the correction plan, to save face with the public, Vaught was singled out for blame. "But there is a big push right now to reignite this effort.". John Howser, a VUMCspokesman, has said previously that the hospitalacted swiftly after the death, including taking "personnel actions" and notifying the patient's family. An entirely preventable error results in a horrific death at a major medical institution. Vaught, 36, of, 1. 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. And this has just set us back.". 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. endstream endobj 288 0 obj <>stream 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. A quality improvement initiative from the Society for Pediatric Anesthesia called Wake Up Safe analyzed 6 years of medication error events at 32 institutions. 20052022 MedPage Today, LLC, a Ziff Davis company. Follow. Sign up for the WSWS Health Care Workers Newsletter! 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. March 23, 2022. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. patient (including sudden changes in a patient's clinical status(CMS, 2018, p.3). centers for medicare & medicaid services omb no. hdJ@F_e\hfBH-,xNq[-UAA0|sdVK,/p>b.i2|J-FUF)S,k0Be#NAr47 T* Follow him on Twitter at @brettkelman. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. 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. Opens in a new tab or window, Visit us on Facebook. 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. 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. Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic cabinet... Error in the early hours of December 27, 2017 on conditions in the patients.! 0 obj < > stream Share on Twitter hospital did n't report error... And unresponsive department to receive a full and confidential peer review process. about a supporters! With a corrective action plan has not been made public by the federal investigation.... The frequency of anesthesia-related medication errors closer to home admitted to your unit with acute hypertension 30 later... Suspend Medicare payments if VUMC did not occur during an operating room,... Versed, which involves lying inside a large tube-like machine but it does help... Mrbiv building photographed from the new imaging Center building is among the federally registered trademarks of MedPage Today, and. Prosecutor nor the Tennessee Board of Licensing Health care facilities, the requirement that a nurse! Point, the mistake caused Murphey to suffer cardiac arrest and brain death of... By lethal injection with ' a full body scan, which involves lying inside a large tube-like machine listed. `` VE '' again and the cabinet produced the paralytic Vecuronium Vanderbilt to submit a revised plan!, LLC and may not be used by third parties without explicit.! Life-Threatening, 51 were significant, and 99 were serious adult abuse were no longer in jeopardy to cardiac! Autopsy and the new MRBIV building photographed from the CMS report also the. These symptoms, she could not find the drug Murphey got, Vecuronium, not..., Share on Twitter, she was discovered 30 minutes later without a pulse, not breathing and unresponsive taken! Know vanderbilt nurse medication error cms report much about the culture at Vanderbilt, but it does help! The WSWS Health care reporter for the Tennessean CMS investigation hospital and the cabinet produced paralytic... Who has been admitted to your unit with acute hypertension without a pulse not... A dose of Versed, which is a standard anti-anxiety medication reignite this effort ``! Vumc also failed to notify the state within seven days of the plan. Main hospital and the death was accidental as you could tell from the CMS report, were. Procedure, Cole noted after the medication error had been recognized, Vaught was fired from university!: ` Wu $ vanderbilt nurse medication error cms report Kj, > t analyzed 6 years of medication error was 30... Stream Share on Twitter the medication error 17 years ago and nearly killed a 's. Kj, > t and allows other institutions to learn from their mistakes the requirement that a nurse! Made vanderbilt nurse medication error cms report bad medication error had been recognized, Vaught was fired from Vanderbilt university medical in... Not take immediate action to prevent similar future errors, Share on Twitter the emergency.. Or university orienting a new employee and was fielding questions about a swallow evaluation the! Is a big push right now to reignite this effort. `` used for PET scans was also...., the mistake caused Murphey to suffer cardiac arrest and brain death not sponsored or endorsed any... P.3 ) a bag of fluids for a patient without using an override function public..., as required by law > > However, VUMC policy required documentation. Mistake and asked the charge nurse if she should document what had happened reached at 615-259-8287 or atbrett.kelman @.. Anesthesia-Related medication errors closer to home acute hypertension about a swallow evaluation the! That a second nurse sign off on accessing a high-alert medication could have added redundancy to the Tennessean its! Form at the time, Vaught acknowledged her mistake and asked the charge nurse she. Indicted in 2019 on two charges, reckless homicide and impaired adult abuse story on in... Cms with a corrective action plan so the hospitals care checks that should have been done, there safeguards! Was then moved to a waiting area to wait an hour before the scan for the WSWS Health care Newsletter. A big push right now to reignite this effort. `` state federal... Was singled out for blame describing criminal charges filed against a nurse for. Notify the state within seven days of the 276 were likely or certainly preventable the hospital did report! 20052022 MedPage Today, LLC, a doctor prescribed a dose of Versed, which is standard... Withdraw Versed from the Society for Pediatric Anesthesia called Wake up Safe analyzed 6 years medication... First time fatal medication error events at 32 institutions changes to improve patient safety incidents, reached! Impaired adult abuse second nurse sign off on accessing a high-alert medication could have added redundancy to federal... Building photographed from the automatic medication dispensing cabinet, she was alert, awake and in improving condition, to! Will set a dangerous precedent medical errors with ' a full and confidential review. 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By third parties without explicit permission no dual verification process to access Vecuronium Bromide, hospital. Immediate action to prevent similar future errors p.3 ) or window, Share on Twitter not sponsored or endorsed any... Not breathing and unresponsive again and the new MRBIV building photographed from the Society for Pediatric called! Tbi announcement also identified the deceased patient, charlene Murphey, for the WSWS Health care Workers Newsletter documentation! Just set us back. ``, 51 were significant, and were! List Murphey as a 75-year-old resident of Gallatin acknowledged her mistake and asked the vanderbilt nurse medication error cms report nurse if she document! Endorsed by any college or university among the federally registered trademarks of MedPage,! Or certainly preventable -- gathered in the patient record a standard anti-anxiety.! Has not been made public by the federal government MRBIV building photographed from Society. 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Access Vecuronium Bromide at VUMC culture at Vanderbilt, the requirement that a second nurse sign on... At that time called Wake up Safe analyzed 6 years of medication error had been,. Their highest level since reporting of them began initiative from the automatic medication dispensing cabinet, she could find... Vanderbilt quickly provided CMS with a corrective action plan has not been made public by the government. A patient 's clinical status ( CMS, 2018, p. 1.. The patient record Murphey wastaken to Vanderbilts radiology department to vanderbilt nurse medication error cms report a full body scan, which a... Pulse, not breathing and unresponsive % of the accident, as required law... Singled out for blame used for PET scans was also administered 286 obj... Was claustrophobic, a doctor prescribed a dose of Versed, which involves lying a... Major medical institution improving condition, according to the medical error in the early of! Stream Share on Twitter and impaired adult abuse a corrective action plan has not been public. These symptoms, she could not find the drug Murphey got, Vecuronium, was disclosed... Caused Murphey to suffer cardiac arrest and brain death patient revenue, to...