At Capacity

The second episode of At Capacity is a follow-up to episode 1. This episode provides much needed context about the day the medication event happened, and aims to connect with the nurse's perspective. Subject matter experts provide explanations about how the environment and technology played roles in the event, as well as an exploration of the system issues that were identified. Listener's hear these voices in order of appearance: Katrina Mikitik, Chrstina, Dr. Ken Catchpole, Nate Farr, Beelah, Dr. Todd Conklin, Patricia McGaffigan, and Dr. Chris LeMaster.

Links:

CMS investigative report

State of Tennessee vs RaDonda Vaught Discovery Document

RaDonda Vaught Says Some System Practices Contributed to Fatal Mistake

Institute for Safe Medication Practices "Call to Action: Standardization and Smarter Logic Needed to Prevent Drug Name Selection Errors"

A KPR Media Production

This premiere episode of At Capacity aims to remind us that the people who enter our healthcare system are very real, and have families and communities who are waiting for them to come home. It examines the story of Charlene Murphey, a 75 year old woman from Gallatin, Tennessee, who died after receiving the wrong medication during a hospital stay in December 2017 This episode walks us through the unusual trajectory this event took and explores the human impact of these situations on patients, families, clinicians, and communities.

Charlene Murphey's Obituary

Anonymous CMS complaint intake form

Anonymous CMS complaint intake form

The Centers for Medicaid and Medicare Services (CMS) Report

Detailed report of CMS' findings after the November 2018 investigation

The Centers for Medicaid and Medicare Services with Vanderbilt's Correctve Action Plan

Includes the medical center's action plan that was submitted in response to the CMS' investigation

Letter from the State of Tenessee Department of Health Division of Health Licensure and Regulation

In October of 2018, the State Department of Health closed their review with no action taken against the nurse's license

Interview with nurse

The nurse talks about being told by an associate nursing officer the reason why she was fired

Comments from medical center's chief communications officer

Article about medication errors

In Episode 1 we made a mistake when we said this was from the Institute of Medicine. It is an article housed at the National Institute of Health: National Library of Medicine: National Center for Biotechnology Information, citation here:

Tariq RA, Vashisht R, Sinha A, et al. Medication Dispensing Errors and Prevention. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519065/

2nd article about medical and medication errors

Institute for Safe Medication Practices (ISMP) alert "Paralyzed by Mistakes"

2016 Alert about neuromuscular blocking agents

Additional great reference:

The Tennessean reporting done by Brett Kellmann (paywall)