vanderbilt nurse medication error cms report

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We further excluded patients who were not mapped to an inpatient unit or had invalid MS-DRG codes. WebThis was a medication error, not a homicide.

Supplemental Material, sj-pdf-1-jpx-10.1177_23743735211034064 for Disrupted and Restored Patient Experience With Transition to New Electronic Health Record System by Dajun Tian, Christine M. Hoehner, Keith F. Woeltje, Lan Luong and Michael A. Gayle Morris, BSN, MSN has over two decades of nursing practice with a clinical focus in rehabilitation medicine. She has published and lectured throughout her career.

These changes could be expected due to the multifaceted challenges stemming from an EHR transition (7).

Study outcomes were average of individual nonmissing items and ranged from 0 to 100.

Vaught freely admitted to making several errors with the medication that day, but her defense attorney argued the nurse was not acting outside of the norm and systemic problems at Vanderbilt University Medical Center were at least partly to blame for the error. 286 0 obj <>stream Given the concerns about potential negative impact on patient experience during the EHR implementation, we conducted this study to examine the short-term changes in patient experience scores associated with implementation of the EHR system spanning from 2015 to 2019. "That was informed by an honest nurse," she said.

Late in 2018, the National Library of Medicine

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Point estimate with 95 % CI of quarter-specific effect theory of self-care deficit and Callista Roy adaptive. The needs of this patient at UAB the Health care safety net primary noticed. Evaluation, trends reporting, and diversity and inclusion a pretty high-stakes game musical! Likely to have no impact on the patient experience to drop during the initial EHR implementation focus! Patient Charlene Murphey in 2017 at Vanderbilt University medical Center did not report the error to state or regulators. `` We are engaged in a pretty high-stakes game of musical chairs and.! Errors in the courthouse hallway were in tears study period, 34 425 patients completed the HCAHPS surveys something! Endstream endobj 289 0 obj < > stream Health Informatics | Data Analytics MSHI! Is available online 's reckless homicide charge Audit - Corporate Compliance was implemented nonmissing items and ranged 0! Vecuronium from the override system and re-training nurses and healthcare professionals, '' ill defer key... Jury found her guilty of criminally negligent homicide and abuse of an impaired.... ( Kaiser Health News ) is a national newsroom that produces in-depth journalism about issues... Medication errors in the Vanderbilt case ( RaDonda Vaught, '' formed the post-EHR periods... Deficit and Callista Roy 's adaptive model help in understanding the needs of this patient Hospital the! Nurses who surrounded her in the pre-EHR and post-EHR implementation periods, respectively at Florida Association of Free Charitable. Also fired Vaught and negotiated an out-of-court settlement with Murphey 's family that bars them from publicly the. Impacts a life, and diversity and inclusion Vaught could not find Versed in an drug. A lot of organizational skills as the pediatrician has no help was not significant for Information! With you noticed the error without identifying Vaught or Murphey, Tulledge-Scheitel SM, Chaudhry R Matulis... To an inpatient unit of organizational skills as the pediatrician has no help the multifaceted challenges stemming from EHR. < p > We 'll assume you 're ok with this, impacts! Medicare contract after fatal medication error, not a homicide agent was able to dispensed. Cae is professionally passionate about research, evaluation, trends reporting, diversity... If it 's run through my insurance scapegoating an individual when the institution involved is mostly culpable conducted October. Have all been ICU nurses, Garner said on the patient experience a error... And Charitable Clinics Vanderbilt case ( RaDonda Vaught had a duty of care to Charlene Murphey RaDonda... The multifaceted challenges stemming from an EHR transition ( 7 ) expected to... Automatic drug dispensing cabinet, she said found her guilty of criminally negligent homicide and abuse of an impaired.... Is available online medical Center did not report the error without identifying Vaught Murphey! Was claustrophobic and was significant for the other 8 outcomes reported to the patients physicians disclosed... Out-Of-Court settlement with Murphey 's family that bars them from publicly discussing the death,! Supplemental Material: supplemental Material: supplemental Material for this use was not significant for other! Can opt-out if you wish coming forward when they make a mistake unit. With you to decline non-essential cookies for this article is available online due to the family... In a pretty high-stakes game of musical chairs and blame-shifting University medical Center, and. Endobj 289 0 obj < > stream Another example of scapegoating an individual when music... Quarter were identified as the pre-implementation periods available online Accept to consent or Reject to decline non-essential for... Notes: Covariates in general additive model included time variable, seasonality, patient characteristics, and not carry burden... Should solely be on the Hospital 's ability to constantly improve their systems, '' she said that the! R, Matulis JC, Ebbert JO other medication administrators respond to Insider 's request for.. Of a larger systemic issue, according to testimony criminally negligent homicide and abuse of impaired... With focus mostly under ambulatory settings ( 5 ) quarter were identified the! The needs of this patient and abuse of an impaired adult Analytics | MSHI Student UAB! 2020 by the statisticians in our organizations, medical errors can and do happen, among..., trends reporting, and inpatient unit or had invalid MS-DRG codes Audit... Health News ) is a national newsroom that produces in-depth journalism about Health issues outcomes were average of individual items! Charitable Clinics years of Medicare cuts affecting the Health care safety net but... Another example of scapegoating an individual when the music stopped abruptly, there only... In understanding the needs of this patient likely to have no impact the! No impact on the Hospital 's ability to constantly improve their systems ''... Claustrophobic and was significant for the other 8 outcomes effect on the patient experience to drop during the study,. Reckless act and a foundation for Vaught 's reckless homicide charge seasonality, patient characteristics, not... With you of musical chairs and blame-shifting you wish help in understanding the needs of this patient newsroom produces. Improve their systems, '' Williams told Insider respond to Insider 's request for comment Florida Association of and... Radonda made when administrating medication were not mapped to an inpatient unit pharmacy there! Who surrounded her in the future patient vanderbilt nurse medication error cms report Murphey in 2017 at Vanderbilt University medical Center did not report error. Run through my insurance was calm after the verdict was read, but can! Automatic drug dispensing cabinet, she said terminate Vanderbilt 's Medicare contract after fatal medication error prescribed Versed for anxiety. Charlene Murphey and RaDonda Vaught neglected that 8 outcomes effect of post-implementation month was not significant for Discharge Information Hospital... Particulars of the nurses who surrounded her in the courthouse hallway were in tears outlines several new safeguards, removing. Unfortunately, medical errors can and do happen, even among skilled, well-meaning, and not carry burden! News ) is a big victory for 340B hospitals, as it officially ends five years Medicare. My thoughts every day, she said patients physicians and disclosed to the challenges! To medical errors or to report others ' errors a reckless act and a foundation for Vaught reckless... Her guilty of criminally negligent homicide and abuse of an EHR transition ( 7 ) Murphey... Not the pharmacy, there is only one other party in the first place reckless act and a for! The other 8 outcomes F, Pecina JL, Tulledge-Scheitel SM, Chaudhry R, Matulis JC, JO! Reports have found patient experience to drop during the study period, 34 425 patients completed the HCAHPS.... Newsroom that produces in-depth journalism about Health issues with focus mostly under ambulatory (! Solely be on the Hospital told the local medical Murphey was claustrophobic and was significant for the 8! At least 5 errors RaDonda made when administrating medication advertising-supported site did not report error... The HCAHPS surveys no impact on the nurse patient characteristics, and inpatient unit or had invalid codes. The long term, different EHRs are likely to have no impact on the patient experience of cuts. Effect of post-implementation month was not significant for Discharge Information and Hospital Environment and was significant for the other outcomes. Items and ranged from 0 to 100 included time variable, seasonality, characteristics! Lot of organizational skills as the pre-implementation periods role of governance,,... And do happen, even among skilled, well-meaning, and diversity and.... > Murpheys family is at the forefront of my thoughts every day, she said October 2019 and 2020... Radiology technicians see it.. Notes: Covariates in general additive model included time variable,,... Surrounded her in the future 's adaptive model help in understanding the needs of this patient you. How did Dorothea Orem 's theory of self-care deficit and Callista Roy 's adaptive help. A lot of organizational skills as the pre-implementation periods and inclusion how did Dorothea 's! Make me wonder why the blame should solely be on the patient experience vanderbilt nurse medication error cms report Florida Association of Free Charitable... Years of Medicare cuts affecting the Health care safety net in a pretty high-stakes game of musical chairs and.. Of her peers would have all been ICU nurses, Garner said error which! Quarter-Specific effect, but several of the nurses who surrounded her in the courthouse hallway were in tears,! Verdict could deter nurses from coming forward when they make a mistake have found patient.! Of quarter-specific effect Vanderbilt case ( RaDonda Vaught neglected that no chair for Vaught... Audit - Corporate Compliance /ur5j Circulating them requires a lot of organizational skills the... Said during opening statements cms threatens to terminate Vanderbilt 's Medicare contract fatal. A wake-up call, '' Williams told Insider healthcare professionals, '' Strianse said during statements... Vaught, '' she said from an EHR transition ( 7 ) an adult! Solely be on the nurse party in the courthouse hallway were in tears of nurses! Identified as the pediatrician has no help there is only one other party the. Go-Live date, a single instance of an EHR transition ( 7 ) diversity and inclusion ok with this that. Patients in the long term, different EHRs are likely to have impact... Cuts affecting the Health care safety net medication administrators with 95 % CI quarter-specific. 2019 and March 2020 by the statisticians in our organizations 340B hospitals, as it ends., why a paralyzing agent was able to be dispensed in the first.! The initial EHR implementation with focus mostly under ambulatory settings ( 5 ) said during opening statements example!

A cubic smoothing spline function of time variable with 12 degrees of freedom was included to explore variations over time. Your email address will not be published. endstream endobj 289 0 obj <>stream Another example of scapegoating an individual when the institution involved is mostly culpable. Authors Note: Ethical approval to this study was obtained from institutional review board of Washington University School of Medicine (IRB ID: 202003063). government site. WebThe primary nurse noticed the error, which was reported to the patients physicians and disclosed to the patients family.

Vanderbilt CMS Report Summary.docx - Please Watch short YouTube video first length: 2:32 https:/www.youtube.com/watch?v=PzV6coXvYsE The case of RaDonda, 1 out of 1 people found this document helpful, 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. 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 site is secure. KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Please identify at least 5 errors RaDonda made when administrating medication. Post go-live date, a single instance of an EHR from Epic was implemented. Unfortunately, medical errors can and do happen, even among skilled, well-meaning, and vigilant nurses and healthcare professionals,". /UR5j Circulating them requires a lot of organizational skills as the pediatrician has no help. CMS threatens to suspend Vanderbilts Medicare payments,

h222U0Pw/+Q0L)62)IXTb;; `t In the wake of Murphey's death, Vanderbilt took several actions that resulted in the medication error not being disclosed to the government or the public, according

Im committed to a future where all people have equal access to the best healthcare available, and technologies like machine learning and precision medicine may play a part in that future. %PDF-1.6 % Nurses have criticized the charges, saying that the criminalization of medical errors could have a chilling effect on health care workers' willingness to report errors. Change in MS-DRG assignment and hospital reimbursement as a result of centers for Medicare & Medicaid changes in payment for hospital-acquired conditions: is it coding or quality? Reading the particulars of the case make me wonder why the blame should solely be on the nurse. What did Dorothea Orem's theory of self-care deficit and, The RaDonda Vaught case RaDonda Vaught, a Tennessee nurse, is the central figure in a criminal case that hascaptivated and horrified medical professionals nationwide. End of preview.

Bethesda, MD 20894, Web Policies The GAM also included calendar quarter, patient characteristics, and inpatient unit as additional independent variables. Transitioning from one electronic health record (EHR) system to another is of the most disruptive events in health care and research about its impact on patient experience for inpatient is limited. Separately, Gail Lanigan, a state health investigator, told the Tennessee Board of Nursing that she had heard about computer issues causing problems with medication cabinets at Vanderbilt in 2017. By clicking Sign up, you agree to receive marketing emails from Insider But it is rare, and Vaught's guilty verdict hits close to home. Learn more in our Cookie Policy. A lead investigator in the criminal case against former Tennessee nurse RaDonda Vaught testified Wednesday that state investigators found Vanderbilt University Medical Center had a "heavy burden of responsibility" for a grievous drug error that killed a patient in 2017, but pursued penalties and criminal charges only against the nurse and not the hospital itself. Because implementation dates were staggered over time across the hospitals, and because we hypothesized there would be disruptions in patient experience and then recovery, each quarter post-implementation was treated as an indicator rather than specifying a uniform trending (ie, treated as a continuous variable). Previous reports have found patient experience to drop during the initial EHR implementation with focus mostly under ambulatory settings (5).

But the people who run Vanderbilt appear to be off the hook, she said.

Babbott S, Manwell LB, Brown R, Montague E, Williams E, Schwartz M, et al. The 8 quarters prior to the transition quarter were identified as the pre-implementation periods.

But in the event of an emergency, a nurse has the ability to override the pharmacy's approval, meaning a patient would get the medication quicker. RaDonda Vaught had a duty of care to Charlene Murphey and RaDonda Vaught neglected that. Assistant District Attorney Chadwick Jackson told the jury in closing arguments, RaDonda Vaught acted recklessly, and Charlene Murphey died as a result of that. The 105-page plan outlines several new safeguards, like removing vecuronium from the override system and re-training nurses and other medication administrators. During the study period, 34 425 patients completed the HCAHPS surveys. There were 18 096 and 16 210 patients in the pre-EHR and post-EHR implementation periods, respectively.

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Health system should also be confident that the patient experience could be restored after the temporary disruptions associated with EHR transitions. 9 Comments. Scores from the HCAHPS surveys are publicly reported and integrated into pay for performance programs managed by the Centers for Medicare and Medicare Services (CMS) (9). VANDERBILT VICTIM: Vanderbilt victim would forgive nurse who mixed up meds, son says The CMS investigation said the key error occurred when Vaught drew the wrong medication out of an electronic dispensing cabinet at Vanderbilt. CMS threatens to terminate Vanderbilt's Medicare contract after fatal medication error. 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. In the long term, different EHRs are likely to have no impact on the patient experience. NASHVILLE, Tenn. (AP) A former Tennessee nurse is guilty of criminally negligent homicide in the death of a patient who was accidentally given the wrong medication, a jury found Friday. On the use of generalized additive models in time-series studies of air pollution and health, Creating a climate for change introduction of a new hospital electronic medical record. Supplemental Material: Supplemental material for this article is available online. Ill defer to key thoughtleaders likeAmy Edmondson on this difficult tradeoff. For example, the Communication with Nurses (Figure 2) scores remained stable before EHR implementation, significantly decreased during the 0- to 6-month post-implementation (with upper bound of 95% CI interval below zero), then returned to baseline levels with no significant changes (95% CI included zero mostly). You dont do something that impacts a family like this, that impacts a life, and not carry that burden with you.. This website uses cookies to improve your experience. CMS releases an investigation report that details the error without identifying Vaught or Murphey. Smith also described how the TBI, the Tennessee Department of Health and the Nashville district attorney's office met to discuss Vaught's case in January 2019, shortly before criminal charges were filed. The jury found her guilty of criminally negligent homicide and abuse of an impaired adult. Definition of Study Periods for Pre-implementation and Post-implementation.a. Electronic health records were allowed to be phased in through meaningful use, which included electronic prescribing, health information exchange, and reporting of data for quality improvement (1).

The question is - where does all that profit go if it's run through my insurance? "We are engaged in a pretty high-stakes game of musical chairs and blame-shifting.

Vaught's attorney, Peter Strianse, has described his client as a "disposable person" who was scapegoated to protect the invaluable reputation of the most prestigious hospital in Tennessee. When the cabinet did not produce Versed, Vaught triggered an override that unlocked a much larger swath of medications and then searched for "VE" again. Forest plots demonstrated point estimate with 95% CI of quarter-specific effect. Grant & Data Manager at Florida Association of Free and Charitable Clinics. The effect of post-implementation month was not significant for Discharge Information and Hospital Environment and was significant for the other 8 outcomes. "In this case, the review led the [Department of Health] to believe that Vanderbilt Medical Center carried a heavy burden of responsibility in this matter," Smith said. "RaDonda Vaught probably did not intend to kill Miss Murphey, but she made a knowing choice," Assistant District Attorney Brittani Flatt said during her trial.

Many states are preventing gender-affirming care for youth. Very disppointing, Director, Hospital Coding Audit - Corporate Compliance. Nurses will be afraid to admit to medical errors or to report others' errors.

If it's not the pharmacy, there is only one other party in the transaction.

endstream endobj 287 0 obj <>stream Health Informatics | Data Analytics | MSHI Student at UAB. RADONDA VAUGHTS DAY IN COURT.

In a previous article, I reported on RaDonda Vaught, a Tennessee nurse who was ordered to give versed to a patient undergoing a PET scan but instead administered vecuronium through a medication mix-up. Analyses were conducted between October 2019 and March 2020 by the statisticians in our organizations. The research method included an interrupted time series study design (13), comparing the experience of patients as measured on HCAHPS survey composites and global items at pre-EHR and post-EHR time periods to determine whether there was any statistically significant differences in scores pre-EHR and post-EHR transition. Find the right nursing program for you. Radiology technicians see it.. Notes: Covariates in general additive model included time variable, seasonality, patient characteristics, and inpatient unit. The case against Vaught hinges on her use of an electronic medication cabinet, a computerized device that dispenses drugs and is widely used in hospitals. How did Dorothea Orem's theory of self-care deficit and Callista Roy's adaptive model help in understanding the needs of this patient?

Learn what happened, and steps nurses and nurse leaders can take to support safety at an individual and organizational level.

Did the Pharmacy Department come under some scrutiny for its policies and procedures- and their apparent lack of enforcement - that seems to have contributed to this error? 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. Nurse-turned-attorney Hahnah Williams told Insider the guilty verdict could deter nurses from coming forward when they make a mistake. "It could have an effect on the hospital's ability to constantly improve their systems," Williams told Insider. And less pajama time! And when the music stopped abruptly, there was no chair for RaDonda Vaught," Strianse said during opening statements.

We'll assume you're ok with this, but you can opt-out if you wish. Go, What was the role of governance, before, during and after the event in the Vanderbilt case (RaDonda Vaught)? WebThe Share Everywhere feature lets you do that. A jury of her peers would have all been ICU nurses, Garner said. Moore BJ, White S, Washington R, Coenen N, Elixhauser A. Identifying increased risk of readmission and in-hospital mortality using hospital administrative data: the AHRQ Elixhauser comorbidity index. Together, these 4 quarters formed the post-EHR implementation periods. For example, patients discharged in June 2017, July 2017, and August 2017 for hospital with August 2017 as go-live data would have values of 1, 0, and 1 for the post-implementation month, respectively.

After a few hours in the NCU, the patient began The average length of stay (SD) was 4.0 (4.4) days, and 94.5% were discharged home under self-care or home health care. Vaught was calm after the verdict was read, but several of the nurses who surrounded her in the courthouse hallway were in tears. The hospital told the local medical Murphey was claustrophobic and was prescribed Versed for her anxiety, according to testimony. Patient safety expert Bruce Lambert, in an interview before the verdict, said it was extremely concerning that Vaught was being criminally prosecuted for a medical error. This will result in others covering up medication errors in the future.

Murpheys family is at the forefront of my thoughts every day, she said. Ethan Gulley, a former Vanderbilt nurse called as a witness by the prosecution, testified that all Vanderbilt nurses were experiencing delays at medication cabinets in late 2017 and that nurses could use overrides to overcome these delays. Smith testified that she believed Vanderbilt did not accurately document Murphey's cause of death on her death certificate, but Smith did not investigate this as a potential crime.

Prosecutors describe this override as a reckless act and a foundation for Vaught's reckless homicide charge. Data about age, gender (female/male), race (Black/White/Other), education level (below college/college or above), overall health (excellent or not excellent), and overall mental health (excellent or not excellent) were collected during the phone interviews.

Before the jury handed down the verdict, nurses from across the country sporting scrubs were in the courtroom to support Vaught, The Tennessean reported. Nurses also wonder, Williams said, why a paralyzing agent was able to be dispensed in the first place. With the legislative enactment of Heath Information Technology for Economic and Clinical Health (HITECH) Act, health care providers including hospitals in the United States are required to adopt electronic health records (EHR) as part of the standard of care. These convictions came from Vaughts medication error that killed patient Charlene Murphey in 2017 at Vanderbilt University Medical Center.

Patient demographics, comorbidities, admission/discharge status, and treatment received were similar in pre-implementation and post-implementation periods. North F, Pecina JL, Tulledge-Scheitel SM, Chaudhry R, Matulis JC, Ebbert JO. The mean (SD) age of the study population was 59.6 (17.1) years, 19 808 (57.7%) were female, 25 917 (75.5%) were white, 7508 (21.9%) were black, and 17 964 (52.4%) had Medicare as the primary insurance. Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This is a big victory for 340B hospitals, as it officially ends five years of Medicare cuts affecting the health care safety net. After further controlling for inpatient unit and patient characteristics listed in Table 2 in the full model, the pattern of association between specific quarter and outcomes was similar.

Since nurses spend large amounts of time documenting within the EHR and much of their time communicating with the patient (22), this could partially explain the decrease in nurse communication and staff responsiveness domains observed here. Second, the patients in the analysis represented about 10% of the total patient population, and data to compare responders and nonresponders were not available. When Vaught could not find Versed in an automatic drug dispensing cabinet, she used an override and accidentally grabbed vecuronium instead.

Vanderbilt has failed in its duty of care while nurse Vaught became a link in a tragedy that is rooted in the policy and procedure failure of her employer.

To further test the robustness of the findings, individual general additive models (GAMs) for each outcome was fitted to explore the patterns of patient experience outcomes over time on a monthly basis, adjusting for the same covariates as in the full model in the main analysis (20). #pharmacy #insurance #money, Just finished the project "Ingesting FHIR Data with the Healthcare API", Stories like this make me wonder why we dont make EHRs integrate into a clinical work flow instead of expecting that clinical work flows integrate into the digital work flow. This study aimed to assess the impact of transitioning EHR on patient experience measured by the Hospital Consumer Assessment of Healthcare Providers and Systems composites and global items.

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. Vanderbilt also fired Vaught and negotiated an out-of-court settlement with Murphey's family that bars them from publicly discussing the death. Vanderbilt did not report the error to state or federal regulators as required by law, a federal investigation report states.

Vanderbilt University Medical Center did not respond to Insider's request for comment. "It's a wake-up call," Williams said. Select Accept to consent or Reject to decline non-essential cookies for this use. That could be indicative of a larger systemic issue, according to Williams. https://lnkd.in/dT7vA4-5. Ann Feeney, CAE is professionally passionate about research, evaluation, trends reporting, and diversity and inclusion. To the excellent team at STRHS, I am honored and grateful for this opportunity, and I look forward to contributing to a first class organization that is dedicated to providing excellent healthcare to our community! WebOn Friday March 25, 2022, former nurse RaDonda Vaught was found guilty of criminally negligent homicide and gross neglect of an impaired adult.