Vanderbilt University Medical Center (VUMC) was the scene of one of the most shocking incidents of medical malpractice in recent memory. A nurse unknowingly gave a 75-year-old patient a fatal injection of the drug used in Tennessee's lethal injection process exclusively reserved for the most murderous criminals. The WSMV report did not disclose the name of the female patient who died. The woman had complained of headaches and problems with vision and a PET scan was ordered. The patient was given 2 mg of Vecuronium instead of Versed prior to the scan.
The victim quickly endured cardiac arrest in what was described as a “torturous” experience because she was awake and aware at the time. The Centers for Medicare and Medicaid (CMS) promptly began an on-site investigation. A local Nashville attorney explained that the incident was the result of several errors made by different people in a “domino chain.”
Findings of Negligence
The CMS report noted the following.
- The facility failed to adhere to proper standards of practice for a safe setting.
- Nursing staff failed to apply their professional skills and training in medication safety.
- The facility demonstrated neglect.
- The hospital submitted a correction plan to prevent such errors.
- The CMS accepted the plan for implementation and the facility will still be eligible for Medicare reimbursement.
John Howser, a chief officer with VUMC, issued a formal statement acknowledging that the error had occurred. He stated that the hospital staff had not adhered to several safety protocols. The family of the patient was notified once the mistake was confirmed. VUMC has since adopted new procedures and conducted appropriate actions regarding personnel that were involved. They are currently working in conjunction with the CMS and the state's Department of Health to reach a resolution.
Adverse Drug Events (ADE)
An ADE involves a patient who is injured as a result of a medication-related mishap. Approximately 50% of these events are determined to have been preventable. ADEs are among the most commonly occurring examples of negligence. This is largely due to the vast amount of medications that are available by prescription or without a prescription. An estimated 700,000 individuals visit an emergency room as a result of these mistakes annually.
Most Common Medication Errors
Errors associated with medications often have severe consequences. Some of the most common include the following.
- Medication is administered without food or water.
- The medication is past its expiration date.
- The patient is given too little, too much or does not receive a dose.
- The medication is administered at an incorrect time of day.
- A patient does not take the medication due to a failure to monitor.
- Giving a patient the wrong product.
- Physicians fail to check for potential drug interactions.
- The product is not administered in the correct form (ie. tablet, capsule, injection or dissolved).
The majority of the mistakes are examples of medical negligence. Often staff does not follow the proper procedures in place. Sometimes the facility fails to properly train the staff. Other causes include mistakes in verbal or written communication, physical or mental exhaustion and other types of human error.