CMS threatens to terminate Vanderbilt's Medicare contract after fatal medication error

CMS has placed Nashville, Tenn.-based Vanderbilt University Medical Center on "immediate jeopardy" status and will terminate the hospital's Medicare provider agreement Dec. 9 unless the deficiencies are corrected.

During an unannounced on-site survey of Vanderbilt University Medical Center in November, CMS learned a patient died at the hospital in December 2017 due to a medication error.

According to an inspection report given to Becker's Hospital Review by CMS, the patient was suffering from hematoma of the brain, headache and other related symptoms when admitted to VUMC on Dec. 24, 2017. The patient was transferred to the hospital's radiology department Dec. 26 for a Positron Emission Tomography scan. While in radiology, the patient requested a drug to help ease anxiety due to being claustrophobic. The physician ordered 2 milligrams of Versed, a drug that is used to treat anxiety. However, a nurse administered 10 milligrams of Vecuronium, a neuromuscular blocking agent.

After the wrong medication was administered, the patient went into cardiac arrest and later died. The hospital failed to report the incident to the Tennessee Department of Health as mandated, according to the inspection report.

"The failure of the hospital to ensure all nurses followed medication administration policies and procedures resulted in a fatal medication error … and placed all patients in a serious and immediate threat to their health and safety and placed them in immediate jeopardy for risk of serious injuries and/or death," states the inspection report.

CMS said VUMC failed to implement measures to mitigate risks of fatal medication errors after the patient's death.

VUMC is working to correct the deficiencies outlined in the inspection report, John Howser, the hospital's chief communications officer, said in a statement to Becker's.

"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," he said. "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 [sic] that any remaining concerns are fully resolved within the specified time frame."

Most hospitals take necessary steps to correct deficiencies prior to termination. A CMS spokesperson told Becker's the hospital plans to submit a revised plan of correction for review by Nov. 30.

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