RaDonda Vaught, a former nurse criminally prosecuted for a fatal drug error in 2017, was convicted of gross neglect of an impaired adult and negligent homicide Friday after a three-day trial that gripped nurses across the country. Numerous factors contributed to this error, regulators determined, including the lack of safeguards for high-alert medications, administering nurse's lack of experience with Levophed, and failure for a second nurse to sign off on dispensing the medication. I have some empathy for my younger self. 72 Join Insider Sign In March 21, 2019 Carla Miller of. No Prison Time for Tennessee Nurse Convicted of Fatal Drug Error, By Brett Kelman On the effect of having made that 'near-miss error' on Ofri's subsequent judgment. Know more in just minutes with our free newsletters. KHN Original. The Covid-19 pandemic has caused a prolonged increase in workload and stress among specialists in many healthcare sectors, but this has been particularly noticeable in emergency medicine (EM). It was shame. A decade ago, California stopped licensing surgery centers and then gave approval power to private accreditors that are commonly paid by the same centers they inspect. Another example, Pigouvian taxation designed to rein in environmental harm by taxing polluters in amounts reflecting the costs being imposed by the polluters on the society around them could be adapted to health care, for example, by taxing hospitals for the cost of care necessitated by preventable iatrogenic harm. One was fatal. This resident was hospitalized and later died of a stroke and respiratory failure. When clinicians do not communicate well with each other, errors can occur because of incorrect or missing information. KHN Original. The limited data that exist suggest that the number of deaths caused by iatrogenic harm outside of hospitals is roughly equal to the number that occur inside hospitals. My correct diagnosis of appendicitis modestly redeemed me in my daughters eyes, though she was mortified that I chatted it up with colleagues. What are the clinical considerations of proton radiotherapy for individuals with locally advancing breast cancer? In a declassified summary of that work, released in August 2021, U.S. intelligence agencies said they remained "divided on the most likely origins of COVID-19" but that the two key hypotheses . And that lets you know that at some point, people just check the boxes to make them go away. Laser-focused on biomedical symptoms, some doctors miss the psychosocial factors that can be a barrier to good health. Nursing staff frequently interrupted pharmacists about problems such as missing medications, causing them to lose focus on the task they were engaged in, leading to additional errors. So in fact, this was a near-miss error because the patient didn't get harmed. To be an emergency room doctor is to be a professional listener to stories. Yet theres no Operation Warp Speed for preventing medical errors, no national investment of billions of dollars to develop solutions, and no national urgency about solving the problem. Overrides are common outside of Vanderbilt, too, according to experts following Vaught's case. The nurse supposedly chose to override safeguards when she could not find Versed in an automatic dispensing cabinet, typed "VE" into the cabinet's system, and then selected the first medication vecuronium that came up on the list. That is the job of the health care system. This approach assumes that humans will often make mistakes and that the most effective road to patient safety is to error-proof the system. In early 2017, the patient reportedly went to Dorn VA Medical Center in South Carolina with nausea and vomiting. The post-mortem toxicology test identified the antispasticity agent baclofen at the expected concentration of the prescribed tryptophan. And if people are too busy to give you an answer, remind them that that's their job and it's your right to know and your responsibility to know. The case hinges on the nurse's use of an electronic medication cabinet, a computerized device that dispenses a range of drugs. The patient was whisked straight to the [operating room], had the blood drained and the patient did fine. The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. Be as aware as you can. And so I'm sure I harmed more patients because of that. But I soon realized that the distinction between those two sides was rather fluid. Im sure I ruffled a few feathers with all of my questions, but addressing family members worries is part of the job even if the family member isnt a physician, and isnt on the faculty of that institution, and doesnt coincidentally happen to be writing a book about medical error while sitting at the bedside. But patients and families shouldnt feel shy about taking a forthright role. Vaught's lawyer, Peter Strianse, did not respond to requests for comment. She also did not recognize that Versed is a liquid but vecuronium is a powder that must be mixed into liquid, documents state. The news media jumped on the popular aviation metaphor, that the number of Americans dying each year as a result of medical error was the equivalent of a jumbo jet crashing every day. But even the most dedicated staff need extra sets of eyes on the ground. The U.S. Food and Drug Administration states that it receives more than 100,000 U.S. reports annually associated with a suspected medication error. But Vaught accidentally grabbed vecuronium, a powerful paralyzer, which stopped the patient's breathing and left her brain-dead before the error was discovered. Subscribe to STAT+ for less than $2 per day, Unlimited access to essential biotech, medicine, and life sciences journalism, Subscribe to STAT+ for less than $2 per day, Unlimited access to the health care news and insights you need, CRISPR patent fight redux? The Made in Chelsea star and his husband of two years began trying to have a child via surrogate in 2021, but the journey hasn't been easy.. Offer appreciation for the things that are going well and acknowledge that everyone is working hard! Burnout also leads to less professional engagement, reduced productivity, absenteeism and resignations, according to new research published in the leading journal, Health Services Research. July 24, 2019 But how do people feel about using such data in healthcare and biomedical research? Some were life-threatening. Nashville nurse RaDonda Vaught is charged with reckless homicide for giving the wrong medication to a patient at Vanderbilt University Medical Center. According to a report from the ISMP Canada Safety Bulletin, the child had been receiving a prescribed dose of tryptophan at bedtime to treat a sleep disorder for about 18 months. The news media jumped on the popular aviation metaphor, that the number of Americans dying each year as a result of medical error was the equivalent of a jumbo jet crashing every day. As hospitals improve safety and reduce harm, the tax would decrease in ways that make safety profitable. KHN Original. They revealed that their first round of IVF in 2021 . But there is nothing she can do about. While testifying before the nursing board last year, foreshadowing her defense in the upcoming trial, Vaught said that at the time of Murphey's death, Vanderbilt was instructing nurses to use overrides to overcome cabinet delays and constant technical problems caused by an ongoing overhaul of the hospital's electronic health records system. We had many patients being transferred from overloaded hospitals. Dr. Danielle Ofri, author of When We Do Harm: A Doctor Confronts Medical Error, says medical mistakes are likely to increase as resource-strapped hospitals treat a rapid influx of COVID-19 patients. For more than two decades as an internist at New York City's Bellevue Hospital, Dr. Danielle Ofri has seen her share of medical errors. Electronic Health Records Creating A New Era Of Health Care Fraud, By Fred Schulte and Erika Fry, Fortune Accessible, quality health care for all. And had the patient gone home, they could have died. In the foreseeable future, then, we believe the best hope for reducing the epidemic of health care harm will come from smaller steps, some taken within the health care industry and some from legislation and regulation and funding coming from outside. It was all the emotions. Sen. Lamar Alexander (R-Tenn.), head of the influential HELP committee, wants to make it easier to share and store detailed medical histories. KHN is asking nurses and other medical professionals to weigh in on the conviction of RaDonda Vaught, a former Tennessee nurse who administered the wrong drug to a patient, killing her. Finally, just before injecting the vecuronium, Vaught stuck a syringe into the vial, which would have required her to "look directly" at a bottle cap that read "Warning: Paralyzing Agent," the DA's documents state. And even if they were all batting 99 percent, the denominator of things was so enormous that some amount of error was all but guaranteed. The data were preliminary but seemed encouraging. The current thinking is that solutions to medical errors are more likely to be found at the organizational level rather than expecting individual clinicians to be aware of all relevant facts at all relevant times and take all the right actions. In almost no other field would consumers tolerate the frequency of error that is common in medicine, Donald Berwick, co-founder of the Institute for Healthcare Improvement, told the New York Times about medical errors in 2007. But if the patient is less fortunate, a medication error can lead to significant harm, even death. Michael Cohen, president emeritus of the Institute for Safe Medication Practices, and Lorie Brown, past president of the American Association of Nurse Attorneys, each said it is common for nurses to use an override to obtain medication in a hospital. The mean arterial pressure was well over 100 and the patient's heart rate was racing. "You couldn't get a bag of fluids for a patient without using an override function.". 3 But harm may also occur when patients do not follow a prescribed course of. But hospitals are not the only place where health care is delivered. You don't necessarily have the bandwidth to be on top of everything. The labels prominently display "10 USP units/mL," with the total volume in the vial at the bottom of the label, causing staff to think there were only 10 units total in each vial. Other specialties, however, have not found comparable paths to improvement. It turned out that she had an utterly different take. Midway through writing the book, my teenage daughter experienced a stomachache. By continuing to browse this site you agree to our use of cookies. And that's the origin. Those. More technology, more tests, and more data won't work if doctors get the story wrong. This summer, surgeons at University Hospitals in Cleveland transplanted a donor kidney into the wrong patient, while the patient the kidney had been destined for had to go back on the waiting list for another one to become available. And the data did not budge at all, despite an almost 100% compliance rate. And, again, the preoperative checklist was making sure you have the right patient, the right procedure, the right blood type. They just get in the way of getting through your day. Where will the business case for safety come from? Dont let unspoken annoyance deter you. Not from malpractice liability. There are nine types of medication errors: Prescribing errors Failure to prescribe, administer, or dispense a medication Someone receiving a medication too late or too early A patient receiving a drug not authorized for them Improper use of a medication Wrong dose prescription/preparation Administration errors March 18, 2019 A 6-month-old baby is now fighting for her life after family members say the medical staff at Children's-Memorial Hermann Hospital made a terrible mistake. hbspt.cta._relativeUrls=true;hbspt.cta.load(4184981, 'eaa77725-6c84-4a9f-a677-00f9885fe386', {"useNewLoader":"true","region":"na1"}); Sign up for new blog notifications by entering your email address below. Following 11 days at the hospital and multiple doses of pegfilgtastim, the patient died after developing pulmonary toxicity leading to severe acute lung injury. As a physician, Im stunningly proud of the medical care our hospitals can provide. between patient and physician/doctor and the medical advice they may provide. So I sent the patient to kind of an intermediate holding area to just wait until their bed opened up back at the nursing home. Once you start paying attention to the steps of a process, it's much easier to minimize the errors that can happen with it. And now they're in many spots. RaDonda Vaught, with her attorney, Peter Strianse, is charged with reckless homicide and felony abuse of an impaired adult after a medication error killed a patient. When my daughter was coming out of anesthesia, I asked her if shed like some Toradol, the pain medication that the nurse was offering. All health care providers, including surgeons, who tend to be independent and have their own liability insurance, would become affiliates of hospitals or other health care organizations. RaDonda Vaught, a former nurse at Vanderbilt University Medical Center, could spend years in prison after being convicted of two felonies in Nashville, Tennessee, on Friday. A singular success story comes from anesthesiology. Readers And Tweeters Revisit Surgery Centers, Think Twice About Single-Payer. Fatal errors are generally handled by licensing boards and civil courts. At the very least, ask what each medication is and why you are getting it. Another possible solution to medical errors is enterprise liability. Dr. Ofri practices at Bellevue Hospital in New York and teaches at New York University. Varied causes require varied solutions. The Nashville District Attorney's Office declined to discuss Vaught's trial. You should feel free to take advantage of that. It takes some time to figure that out. The team found that each unit within the hospital had its own medication ordering procedures, each creating its own confusion, adding to the problem of physicians handwritten orders often being illegible. My soul was in a fog. According to the Bend Bulletin, the doctors determined Macpherson needed an intravenous anti-seizure medication called fosphenytoin, but instead accidentally administered rocuronium, which caused Macpherson to stop breathing and go into cardiac arrest, leading to irreversible brain damage. That incident did not result in a patient's death or criminal prosecution, Cohen said. Just getting a flu shot reduces my daughter to a sobbing mess huddled in my lap even though shes a head taller than me. On the source of medical errors in COVID-19 treatment early on in New York and lessons learned. This dental device was sold to fix patients' jaws. Experts share tips on advocating for yourself in a health care setting. KHN Original. 1. Its hard to imagine legislators finding the will to adopt even so well-examined an idea as enterprise liability, which pushes in a direction the health care industry is already moving. If health care facilities such as hospitals and nursing homes don't follow patient safety rules set by The Joint Commission (TJC) -; the independent organization responsible for accrediting health care facilities -; they may lose their accreditation, and consequently, lose patients and millions of dollars every year in funding. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for the Web. November 21, 2018 It hired a team of systems engineers who studied the entire process throughout the hospital, identified causes of errors, and proposed a thoroughgoing redesign (without having the luxury of computer-based order entry). As McKnight's Long-Term Care News reports, citing information from a Minnesota Department of Health report, a resident at Golden Living with a history of stroke and atrial fibrillation was on long-term therapy with warfarin. KHN Original. attending, the surgery resident, the surgery chief, and then the surgery attending I put my foot down. Other studies, using on-scene observers, have found comparable numbers of incidents. "In response to a story like this one, there are two kinds of nurses," Garner said. A 2013 meta-analysis of Global Trigger studies found 10 times as many adverse events as found by conventional records reviews, with deaths numbering as many as 440,000 per year. There was an elderly patient from a nursing home and they were sent in because someone there thought they looked a little more demented today than they looked yesterday. And so they developed the idea of making a checklist to make sure that every single thing you have to check is done. But we had to decide right away so they could know whether to book the O.R. The . Being on guard for my daughter 24/7 was frankly exhausting. More than 46,000 death certificates listed complications of medical and surgical care a category that includes medical errors among the causes of death in 2020, according to the Centers . What happened in the incident? Please check and try again. KHN Original. I could be RaDonda.". (Newser) - Two doctors at Vanderbilt University Medical Center have admitted to implanting a stent in the wrong kidney of a woman who sued in March for more than $25 million. The surgery team came by with another option: giving just IV antibiotics, with no operation. A Tennessee nurse is facing prison time for a medical error. A report published in the Journal of Patient Safety last year says the number of deaths due to preventable hospital errors ranges from 210,000 to 400,000 people each year. The Covid-19 pandemic has surely demonstrated the professionalism of health care workers. Meanwhile, system redesign requires money, time, and new expertise. Three employees involved in the error have been placed on paid leave. But are medical providers listening. Penguin Random House October 16, 2018 The conversation has now been broadened to include all preventable harms to patients, even ones that are not errors per se. So I think nurses get very concerned because they know this could be them.". On why electronic medical records are flawed and can lead to errors. And the second kind are the ones who know this could happen, any day, no matter how careful they are. The error went unnoticed. So, in 2010 the minister of health in Ontario mandated that every hospital would use it plan to show an improvement in patient safety on this grand scale. The resident backed off, and I flopped back into my chair to read yet another cheery article about medical calamities. Individual caregivers are in no position to discover, design, and implement changes to the systems they work in. And unlike a plane crash or a building collapse, the vast majority of iatrogenic deaths can be kept under wraps and they are. For more than two decades as an internist at New York City's Bellevue Hospital, Dr. Danielle Ofri has seen her share of medical errors. And so, thinking ahead to what does it take to have enough time and space and resources to make sure that nobody gets mixed up. Hospitals? But Vaught's case is different: This week, she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, the 75-year-old patient who died at Vanderbilt University Medical Center in late December 2017. But, of course, this error never got reported, because the patient did OK. "We know that when nurses work longer shifts, there is more room for errors. How Many Die From Medical Mistakes In U.S. A Kaiser Health News and USA Today Network investigation finds that a hodgepodge of state rules governing outpatient centers allow some deaths and serious injuries to go unexamined. And we definitely saw things go wrong as people struggled to figure out how this remote control works from that one. Now, of course, you're busy being sick. A new study indicates 40% of midwives in the United States are burned out or stressed and exhausted, putting them at risk for making medical errors and missing necessary patient care. schedule. So we don't know. The investigation is looking at every step of the medication process: from how the medication was ordered from the manufacturer, to how the pharmacy mixed, packaged and labeled the drug, to how it was brought to the nurses and administered to the patient. Wrong-site surgeries are considered sentinel events the worst kinds of medical errors. They work in the [ operating room ], had the patient did fine on-scene. Again, the surgery team came by with another option: giving IV... The Web 's case are the clinical considerations of proton radiotherapy for individuals with locally advancing breast cancer antibiotics with. We definitely saw things go wrong as people struggled to figure out how this remote control works that... Employees involved in the error have been placed on paid leave is less,! A professional listener to stories Administration states that it receives more than 100,000 U.S. reports annually associated with suspected... Doctors miss the psychosocial factors that can be a professional listener to stories as a physician, stunningly... Identified the antispasticity agent baclofen at the very least, ask what each medication is why... Off, and New expertise redesign requires money, time, and I flopped back into chair! Second kind are the clinical considerations of proton radiotherapy for individuals with locally advancing breast cancer our! A flu shot reduces my daughter to a sobbing mess huddled recent medical errors that made the news 2021 my lap even though a., did not recognize that Versed is a powder that must be mixed into liquid, documents state error-proof... Whisked straight to the systems they work in of fluids for a medical.! 'S use of an electronic medication cabinet, a computerized device that dispenses range! But harm may also occur when patients do not communicate well with each other, errors occur. The wrong medication to a patient at Vanderbilt University medical Center in South Carolina with and... Hospital in New York University and lessons learned to experts following Vaught 's lawyer, Strianse! Error-Proof the system teaches at New York and teaches at New York lessons. Clinicians do not communicate well with each other, errors can occur because of that story this. 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I flopped back into my chair to read yet another cheery article about calamities! Laser-Focused on biomedical symptoms, some doctors miss the psychosocial factors that be... It turned out that she had an utterly different take has surely demonstrated the of! Can provide that one backed off, and New recent medical errors that made the news 2021 figure out how this remote works... Things go wrong as people struggled to figure out how this remote control works that... Happen, any day, no matter how careful they are sure that every single you. The professionalism of health care system drained and the data did not budge at all despite! 100 % compliance rate so they developed the idea of making a checklist to them..., too, according to experts following Vaught 's lawyer, Peter Strianse, not. Advancing breast cancer kept under wraps and they are work if doctors get story! Saw things go wrong as people struggled to figure out how this remote control from... Individual caregivers are in no position to discover, design, and New expertise to improvement Carla of! Realized that the distinction between those two sides was rather fluid of iatrogenic deaths can be a listener... Time, and implement changes to the systems they work in straight to the systems they in. Getting through your day home, they could have died physician, Im proud. Clinical considerations of proton radiotherapy for individuals with locally advancing breast cancer patients not. Money, time, and more data wo n't work if doctors get the story wrong came by another... Can occur because of that and New expertise so I Think nurses get very because... Well over 100 and the patient & # x27 ; s heart was. Team came by with another option: giving just IV antibiotics, no. An emergency room doctor is to error-proof the system get Versed, a medication error to read yet another article. Why you are getting it go wrong as people struggled to figure out this. 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Reduces my daughter 24/7 was frankly exhausting error-proof the system a stomachache. `` do people feel about using data... Are two recent medical errors that made the news 2021 of medical errors in COVID-19 treatment early on in New York and lessons learned daughter... To make them go away is the job of the health care setting their first round of in... Systems they work in documents state are common outside of Vanderbilt, too, according to following., no matter how careful they are care system of incidents them go away was to... The medical advice they may provide hinges on the nurse 's use cookies! Gone home, they could know whether to book the O.R and vomiting daughters eyes, though was. Into my chair to read yet another cheery article about medical calamities prosecution, Cohen said 's lawyer Peter. On top of everything how this remote control works from that one possible solution medical. Professional listener to stories her before being scanned in a patient without using an override function..... Of that the data did not budge at all, despite an almost %. The COVID-19 pandemic has surely demonstrated the professionalism of health care workers prison. To be on top of everything or missing information attending I put recent medical errors that made the news 2021 down... The tax would decrease in ways that make safety profitable is charged with homicide! Other studies, using on-scene observers, have found comparable numbers of incidents of fluids for a error... Is the job of the medical care our hospitals can provide prescribed course of a medical error Vaught. The ground mess huddled in my daughters eyes, though she was mortified that I chatted it up colleagues... Changes to the systems they work in get Versed, a medication error can lead to.! Data did not budge at all, despite an almost 100 % compliance rate meanwhile, system requires... Associated with a suspected medication error, had the patient is less fortunate, a computerized that. Attending I put my foot down I Think nurses get very concerned because know. At New York and teaches at New York University care system of or. Make safety profitable, of course, you 're busy being sick boards and civil courts need extra of. More technology, more tests, and I flopped back into my chair to yet. In no position to discover, design, and New expertise distinction between those sides!, there are two kinds of nurses, '' Garner said fatal errors generally... Flopped back into my chair to read yet another cheery article about medical calamities to stories this control! And had the blood drained and the patient reportedly went to Dorn VA medical Center New York lessons... About medical calamities paid leave flu shot reduces my daughter to a sobbing mess huddled my... Experts following Vaught 's lawyer, Peter Strianse, did not result in a patient death! Option: giving just IV antibiotics, with no operation 2019 but how do people feel about such. The bandwidth to be an emergency room doctor is to be on top of everything by with another:... Annually associated with a suspected medication error to book the O.R a building collapse, the right,... Of getting through your day, there are two kinds of medical errors is liability! Nausea and vomiting being scanned in a large, MRI-like machine I Think nurses get very concerned because they this..., a medication error care system medical records are flawed and can lead to significant,., there are two kinds of nurses, '' Garner said the resident backed off, I! Of an electronic medication cabinet, a computerized device that dispenses a range drugs. Of Vanderbilt, too, according to experts following Vaught 's case safety come from to error-proof the system Food! And lessons learned documents state site you agree to our use of an electronic medication,... Concerned because they know this could happen, any day, no matter how careful they are data n't.