Medical error leads to change at UVM Medical Center

The University of Vermont Medical Center in Burlington has made changes after a patient died from an accidental Ketamine overdose administered by a nurse.

The patient came to the hospital's emergency department in January with shortness of breath. A physician instructed a nurse to give the patient two drugs: a muscle relaxant and one dose of Ketamine. Instead of giving the patient one dose of Ketamine, however, the nurse drew an entire vial of the drug into a syringe and administered all of it, or five times the amount the physician prescribed, according to a VPR report based on an inspection report by the state's Division of Licensing and Protection.

Two days after the accident and the patient death, the hospital performed a root cause analysis and developed a plan to improve patient safety at the hospital. For instance, the hospital looked into getting smaller dosing vials of Ketamine to avoid this issue. Another solution was a mandatory education module for nurses about only drawing the ordered amount of a drug into a syringe.

When the Division of Licensing and Protection visited UVM Medical Center in March, the inspectors found that "none of the plans had been initiated," according to the VPR report.

However, Stephen Leffler, MD, the hospital's CMO, says the hospital "immediately implemented changes to address the causes that were determined to lead to the event" after the root cause analysis was performed two days after the incident.

Mike Noble, a UVM Medical Center spokesman, told VPR that "the education process was initiated and started" at the time of the DLP visit. "It was not completed before they arrived because there are a number of people that need to go through the module, and it does take some time."

The hospital also started using smaller vials of Ketamine on March 19, according to VPR.

UVM Medical Center is "fully and completely focused on improving processes to protect our patients" Dr. Leffler says.

Editor's note: This article includes new information and is run under a new headline to better construe the steps UVM Medical Center took. The original headline, "UVM Medical Center waited weeks to update processes after medical error, report finds" poorly communicated the fact that UVM took steps immediately after the incident and may have left some readers confused. We regret this error.

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