A recent fatal medical mistake at Vanderbilt University Medical Center is now jeopardizing the Medicare reimbursement status of Nashville’s largest hospital. According to a recent article in the Tennessean, the incident took place in December 2017 when a nurse, who confused two different drugs because they started with the same letters, accidentally administered a lethal dose of the wrong medication to a patient.
The death was discovered by regulators from the Centers for Medicare & Medicaid Services (CMS) during an unannounced visit to the hospital last month. A CMS report notes the patient died not only as a result of being given the wrong medication, but also a significantly high dose of the drug.
According to the report, the patient, who was otherwise medically stable at the time, had been nervous about a receiving a full-body scan in the hospital’s radiology department for a hematoma in the brain and related symptoms, and was prescribed 2 mg of a routine anti-anxiety medication known as Versed by a doctor. The attending nurse then used the hospital’s electronic medication dispersing cabinet to search for the name of the drug.
Unable to find “Versed” in the system, the nurse prompted an override of the computer, which unlocked access to more powerful and tightly controlled medications. The nurse then searched for “VE” in the system instead of “Versed,” and chose the first search result delivered by the computer. Tragically, that medication was a powerful anesthetic known as vecuronium. Despite the doctor’s 2 mg prescription, the nurse injected the patient with 10 mg of vecuronium, a dose which caused the patient to go into cardiac arrest, suffer partial brain death, and later die.
Regulators’ Actions Speak to Severity of Medication Errors
Upon discovery of the patient death, CMS regulators noted that despite the seriousness of the medication error, Vanderbilt failed to take appropriate corrective action or adopt new policies to prevent similar incidents.
Although the hospital has claimed it took appropriate action by terminating the nurse and disclosing the error to the patient’s family, regulators said the hospital failed to report the incident to the Tennessee Department of Health as required by law. They also found hospital staff failed to appropriately monitor the patient after administering the medication, and were not aware of any problem until the patient had been in the scanning machine for roughly half an hour.
The hospital’s failures to mitigate risks following the incident, the CMS report says, is a sign of their failure to ensure competent care and the safety of all patients, and puts patients at immediate risk of serious injuries or death.
The mishap and the hospital’s subsequent failures were so egregious that regulators notified Vanderbilt officers the facility no longer meets requirements to participate as a provider for Medicare services, which account for nearly a quarter of the hospital’s net patient revenue, and are threatening to revoke their provider status. CMS officials are requiring Vanderbilt to submit a revised corrective plan by November 30. If their plan fails to meet CMS standards, the hospital could lose its Medical reimbursement status on December 9.
Medication Errors, Medical Malpractice & Victims’ Rights
This particular medical mistake is one that comes with tragic and life-altering consequences. It is also one which highlights the failures of not only the nurse involved, but also the hospital. Medical facilities have a legal obligation to take steps that prevent and reduce risks for these types of tragedies, ensure medical emergencies are promptly identified and addressed, and comply with various regulations for reporting and corrective action. According to federal regulators, Vanderbilt fell short in meeting all those duties.
As Vanderbilt’s Medicare status hangs in the balance, it is important to remember that any regulatory penalties hospitals face following such incidents do not provide a viable form of compensation for victims. Families who lose loved ones as a result of medical mistakes, and who must deal with the many economic and non-economic damages sudden and preventable deaths can create, would need to assert their rights in the civil justice system. Medical malpractice and wrongful death lawsuits are intended precisely to address these types of losses, ensure accountability, and provide victims and families with the justice and compensation they deserve.
Kinnard Law is a Nashville trial law firm that has been serving victims and families throughout Tennessee Since 1977. Over the years, our attorneys and Board-Certified Medical Malpractice Specialists have secured record-setting verdicts and national awards, as well as millions of dollars in compensation for clients. Attorney Randall Kinnard has also successfully litigated against Vanderbilt, most recently by securing a multimillion verdict on behalf of a client whose biopsy sample went missing.
For more information about our firm and the services we provide, contact us.
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