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Nashville, Tenn. – Eleven months ago, a nurse at the Vanderbilt University Medical Center accidentally selected the wrong medication while attempting to administer a sedative routine to a patient, injecting him with the lethal dose of a paralyzing anesthetic.
The mistake, which caused the death of an otherwise stable patient, has now compromised the Medicare reimbursement status of one of Nashville's largest and most prestigious hospitals.
Medicare accounts for about one-fifth of VUMC's turnover, according to the hospital's latest financial reports.
Federal officials say that if they are not badured that Vanderbilt can put safeguards in place to prevent future mistakes, the government will stop paying for Medicare beneficiaries at the hospital.
Vanderbilt has submitted a corrective plan earlier this month and a revised plan is due Friday, according to April Washington, a spokeswoman for the Centers for Medicare and Medicaid Services.
John Howser, a spokesman for VUMC, said in a statement that the hospital was working with federal officials to resolve issues by the deadline. Howser added that the hospital had already taken "the necessary corrective measures".
"When examining the event at the time it occurred, we found that the error was due to the fact that one staff member had bypbaded the multiple security mechanisms in place to prevent such mistakes, "said Howser. "We disclosed the error to the patient's family as soon as we confirmed that an error had occurred and we immediately took the necessary corrective actions (including appropriate staffing measures)."
Versed or vecuronium: a deadly mistake
Neither the patient nor the nurse in charge were identified in the accidental death documents.
A survey report published by Centers for Medicare and Medicaid Services explains in detail how much the mistake resulted from the fact that the nurse confused two drugs because their names started with the same letters.
The report states that the patient entered Vanderbilt on December 24, 2017, suffering from a subdural hematoma – or a bleeding brain – and a loss of vision. The patient was sent to the radiology department of the hospital for a full body scan, involving placement in a large tubular machine.
The patient is worried about the presence of claustrophobia in the machine, explains the report. A doctor prescribed a small dose of Versed, a standard anti-anxiety sedative.
The nurse recovered the drug in a medicine cabinet, but removed the vecuronium, a neuromuscular blocking drug that causes paralysis. The nurse then gave the patient the vecuronium without knowing it, saying it was "something to help her relax," according to the investigation report.
The patient became unresponsive to the CT scan, suffered cardiac arrest and partial brain death. The patient died three days later after being removed from a respirator.
During an interview with investigators, the nurse said that the drug change had occurred because the nurse was struggling to find the Versed in the dispensing cabinet. Unable to locate the drug, the nurse triggered a "priority setting" in the cabinet, which unlocked more powerful drugs.
The nurse then entered the first two letters of the drug name – "VE" – into a search field and then selected the "first drug on the list".
It was vecuronium, not Versed.
According to the investigation report, Vanderbilt also failed the patient by not monitoring the person after the drug was dispensed.
Nurses are supposed to monitor patients after administering medications to make sure they do not react badly. But in this case, the patient was moved to the scanning device, so that it was not immediately noticed when the person lost consciousness. The medical staff felt that the patient may have been alone in the scanning device for 30 minutes before anyone noticed anything that was wrong.
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