NASHVILLE (WSMV) — Vanderbilt University Medical Center is under review after a nurse mistakenly gave a patient a fatal dose of the wrong medication in December of last year.
The patient, a 75-year-old female who has not been identified, was admitted to the hospital for headaches, vision loss, and other related symptoms. The patient was scheduled for a PET scan and requested medication to help with claustrophobia that can be induced from PET scans.
A nurse, who also has not been identified, was supposed to give the patient two milligrams of Versed, a drug that helps treat anxiety. The nurse accidentally gave the patient a deadly dose of Vecuronium, a drug that causes paralysis.
“The nurse who went to retrieve the Versed in this case instead retrieved the lethal injection drug. It’s the drug used in the lethal injection protocol in Tennessee and other states to execute murderers and serial killers,” said Brian Manookian, a Nashville attorney who handles a lot of wrongful death cases.
The patient suffered cardiac arrest and died in the days following the incident.
“She would have fully experienced torturous, searing pain as her lungs shut down and she was unable to verbalize what was occurring being fully awake and aware the entire time," Manookian told News4's Kim St. Onge.
The mistake prompted the Centers for Medicare & Medicaid Services (CMS) to investigate VUMC. According to a report obtained by News4, CMS conducted and unannounced, onsite survey from October 31 to November 8 of this year.
The findings of the survey included the following:
1. The hospital failed to ensure all patients received care in a safe setting and staff followed standards of practice and utilized their nursing skills and training to ensure the correct medications were administered to all patients.
2. The hospital failed to ensure patients were free from neglect.
The full report can be read here.
The hospital was forced to submit a "plan of correction" detailing plans to prevent similar errors from taking place in the future. CMS has accepted VUMC's plan, according to CMS Press Officer April Washington, and the hospital is no longer in jeopardy of losing Medicare funding.
John Howser, the Chief Communications Officer at VUMC, sent News4 the following statement:
VUMC was notified of an adverse finding by the Tennessee Department of Health after an on-site survey involving a patient who died in December 2017 following a medication error. In reviewing the event at the time it happened, we identified that the error occurred because a staff member had bypassed multiple safety mechanisms that were in place to prevent such errors. We disclosed the error to the patient’s family as soon as we confirmed that an error had occurred, and immediately took necessary corrective actions (including appropriate personnel actions). We will continue to work closely with representatives of Tennessee Department of Health and Centers for Medicare and Medicaid Services to assure that any remaining concerns are fully resolved within the specified time frame.
Washington said that VUMC is now under an ongoing review following the acceptance of Vanderbilt's plan of correction.