14 hours ago · In November 2018, the Centers for Medicare and Medicaid Services (CMS) issued a Statement of Deficiencies concerning the death of a patient at Vanderbilt University Medical Center (VUMC). The 56-page report included staff statements about medical errors and hospital staff conduct that constituted a cover-up. >> Go To The Portal
Instead, the reporting doctor attributed the death to bleeding in the patient’s brain and vecuronium was never mentioned, the official told federal officials. “We released jurisdiction because there was an MRI that confirmed the bleed,” said the medical examiner's official, who is quoted in the federal report but not named.
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 report noted that “Vecuronium has a history of causing catastrophic injuries or death when used in error.” ) In addition to the vecuronium, a radioactive-tracer required for the PET scan was also administered. Charlene was then moved to a Radiology waiting room for PET scan patients.
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.
When Nurse Vaught was interviewed by an investigator for CMS, she said that after administering the medication she put the remaining medication in a baggie and gave it to nurse #2. About 15 minutes later Nurse #2 looked at the bag and saw it was vecuronium. Nurse #2 questioned Nurse Vaught and verified that vecuronium was given to the patient.
RaDonda Vaught, 37, was also found guilty Friday of gross neglect of an impaired adult in a case that has fixed the attention of patient safety advocates and nurses' organizations around the country. Vaught injected the paralyzing drug vecuronium into 75-year-old Charlene Murphey instead of the sedative Versed on Dec.
In the RaDonda Vaught case, her hospital reported that the patient died of natural causes instead of notifying federal regulators of the medication error as required by law.
Risk of Death due to Medication Errors Administration of vecuronium bromide results in paralysis, which may lead to respiratory arrest and death; this progression may be more likely to occur in a patient for whom it is not intended.
vecuroniumVaught, 39, was found guilty last week in the 2017 death of Charlene Murphy. Murphy was a patient at Nashville's Vanderbilt University Medical Center when Vaughn inadvertently injected Murphy with a deadly dose of the paralyzing drug vecuronium.
She is now currently on trial for reckless homicide and adult abuse. The case of RaDonda Vaught, now 36, has spurred major conversations about nurses, how they are supported or not by the hospitals they work, and if a nurse who made a mistake should be considered guilty of homicide.
Ex-nurse RaDonda Vaught found guilty on two charges in death of patient. A jury on Friday convicted former Nashville nurse RaDonda Vaught of criminally negligent homicide and abuse of an impaired adult after a medication error contributed to the death of a patient in 2017.
Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. In this case, the drug appears to have caused the patient, who was otherwise stable, to lose consciousness, suffer cardiac arrest and ultimately be left brain dead.
There is a Black Box Warning for this drug as shown here. Common adverse reactions include immunologic: anaphylaxis, hypersensitivity reaction, musculoskeletal: muscle weakness, Prolonged neuromuscular block,respiratory: bronchospasm.
Since vecuronium is given by a healthcare professional in a medical setting, an overdose is unlikely to occur.
The registered nurse (RN) may administer Propofol, Etomidate and neuromuscular blocking agents (only Succinylcholine, Rocuronium and Vecuronium) to the non-intubated patient in a hospital setting for the purpose of rapid sequence intubation when the clinical presentation of impending respiratory failure is imminent.
No prison time for RaDonda Vaught, former Vanderbilt nurse convicted of fatal drug error | WPLN News.
(WSMV) - Nurses across the country say they are quitting their jobs after RaDonda Vaught was found guilty. A jury found Vaught, a former Vanderbilt University Medical Center nurse, guilty of criminally negligent homicide.
After a patient receives a neuromuscular blocker, progressive paralysis develops, initially affecting the small muscle groups such as the face and hands, then moving to larger muscle groups in the extremities and torso until all muscle groups are paralyzed and respiration ceases.
Apparently didn’t look at exactly what it was because most people that I’ve talked to have said that vecuronium has a label on it, a warning label big that says warning paralytic agent. Gives the medication, administers it to the patient and they put her in the scanner. Now mistake number one.
In other words it doesn’t sedate you , it doesn’t make you unconscious, it paralyzes your muscles, including your skeletal muscles, including your diaphragm and your muscles of respiration, your intercostal muscles that help you breathe. Well, this was not a good thing because the nurse took the drug.
Instead, it appears that a Vanderbilt doctor told the medical examiner’s office that the patient died from bleeding and that any medication errors were purely “hearsay,” according to the investigation report.
The nurse then typed the first two letters in the drug’s name – “VE” – into the cabinet computer and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed. The drug was then given to the patient, who was then put into the scanning machine before anyone realized a medication mistake had been made.
Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states. In this case, the drug appears to have caused the patient, who was otherwise stable, to lose consciousness, suffer cardiac arrest and ultimately be left brain dead. The patient died one day later after being taken off ...
26 while the patient was being treated at Vanderbilt for a subdural hematoma – or bleeding in the brain – that was causing a headache and loss of vision. Despite these symptoms, the patient was alert, awake and in improving condition, according to the federal investigation report.
Instead, Howser stressed that the patient's death was reported to the medical examiner within 40 minutes, before there was a “definitive conclusion” about the cause of death. He did not address the fact that the medication error had occurred the preceding day. “The report to the Medical Examiner’s office was made promptly and in good faith ...
During a separate interview with federal officials, a medical examiner’s official said Vanderbilt should have informed him about any error involving a paralyzing medicine. Instead, the reporting doctor attributed the death to bleeding in the patient’s brain and vecuronium was never mentioned, the official told federal officials.
Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. Follow him on Twitter at @brettkelman. More: At Vanderbilt, a nurse's error killed a patient and threw Medicare into jeopardy.
Investigational drugs. ISMP receives frequent reports of hazards and errors related to investigational medications. Labeling and packaging issues, again, are common due to limited regulatory guidance.
Dr. Norenberg agreed that the Vanderbilt error underscores the limits of ADCs and other medication safety technology. As noted, the Joint Commission standard recommends that all medication orders be reviewed by a pharmacist. The ADC can provide this oversight, to a point, limiting access to certain drugs. “But if one overrides the controls in the ADC to gain access to the medications, this effectively removes all the safeguards that have been put in place,” he explained.
Look-alike drug names. In one case, a nurse transcribed a verbal order for NARCAN (naloxone) correctly, but a pharmacist misread the order and dispensed NORCURON (vecuronium). According to the ISMP report, the nurse thought Norcuron was the generic name for Narcan and administered the NMBA. Unsafe mnemonics.
At the ASHP 2018 Midyear Clinical Meeting, the Institute for Safe Medication Practices (ISMP) presented its annual look at some of the top medication safety issues reported to the organization. Leading the list were labeling and packaging issues, drug allergy interactions, vaccine errors, medication errors related to incorrect patient weights, methotrexate errors, and investigational medication safety issues, among others, according to ISMP’s Christina Michalek, RPh, FASHP.
The International Medication Safety Network (IMSN), for example, will be preparing a white paper on best practices for drug product labeling and packaging, and the Partnership for Health IT Patient Safety Drug Allergy Interaction Workgroup will be posting a tool kit based on their work in early 2019.
Blister packs (see photo) are an effective diversion-resistant packaging option, the IS MP noted. If opioids were packaged in three- or six-day blister packs to prevent abuse and diversion, more physicians would prescribe them, according to ISMP. Documenting weight.
These repeated tragedies show that “directors of pharmacy have been hitting the snooze button on this for at least 25 years ,” said Jeffrey Norenberg, PharmD, PhD, the director of the radiopharmaceutical sciences program in the College of Pharmacy at the University of New Mexico Health Sciences Center, in Albuquerque.