A nurse’s medication error at a leading hospital in Tennessee caused a patient’s horrific death, and the hospital nearly lost its Medicare reimbursement status as a result. The question is whether the nurse alone is to blame or whether there were also failures in the hospital’s systems.
The medication error occurred nearly a year ago at the Vanderbilt University Medical Centre but only became public recently. A full body scan was ordered for a stable patient, who had suffered a subdural hematoma. The patient expressed anxiety about the procedure as she had claustrophobia and her doctor prescribed Versed, which is a sedative. When the nurse was unable to locate Versed, she triggered an override setting on Pyxis, and after having typed in “Ve” the first medication that came up was vecuronium which she then retrieved and administered to the patient.
Whereas the trade-named Versed, is an anxiolytic drug, generic vecuronium is used in anesthesia as a neuromuscular blocking agent that leads to paralysis. It is also used as a lethal injection in executions.
A second mistake was that the patient was moved into the scanner right away and not monitored for the effect of the drug. While the scan was in progress, the patient would have been fully alert while experiencing progressive paralysis, and probably extreme pain when unable to breathe, until she lost consciousness and experienced cardiac arrest. Estimates are that the patient was in the scanner for around 30 minutes before anyone noticed that anything was wrong. She was transferred to ICU and passed away the following day.
The hospital reported in a recent statement that at the time of the event it had been reviewed, and corrective action is taken immediately. The patient’s family had also been notified of the error. However, the hospital failed to report the incident to the Tennessee Department of Health — as required by law. It only came to light during an unannounced on-site survey by Centers for Medicare and Medicaid Services (CMS) in November this year.
According to the CMS report on its survey:
“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.
The hospital failed to ensure patients were free from neglect.”
The CMS placed VUMC on jeopardy status, where it would no longer receive Medicare reimbursement unless the required corrective actions were taken. This would have had a significant impact on the hospital as these reimbursements represent about one-fifth of its income. A corrective plan to prevent similar errors from occurring in the future has now been submitted by VUMC and accepted by the authorities. It no longer stands to lose Medicare payments but is still under ongoing review.
It is evident that the nurse in this incident neglected to follow the Rights of Medication Administration and then to monitor the patient – which would be required even after administration of Versed. Recent comments by health care providers, however, do indicate that there were also facility errors, especially because the drug could be removed from the system with a simple override and typing in only the first two letters.
Suggestions to improve systems included that access to paralytics should be disabled on Pyxis outside of certain clinical areas (such as operating theatres and ICU’s) or only be available for individuals with certain skill sets; that systems should require the full name of a medication to be typed in, and that two people should be required to sign out on high-risk drugs.
Health care providers should also guard against all the safety rules and procedures allowing them to become complacent, and in the process neglect to apply critical thought and common sense.