December 12, 2018 | Marcus Miller

All Eyes are on Vanderbilt University Medical Center

Vanderbilt University Medical Center had a medication error that resulted in a patient’s death in the early hours of Dec. 27, 2017. I read the CMS (Centers for Medicare & Medicaid Services) Statement of Deficiencies and was astonished with the sheer number of opportunities Vanderbilt has to learn from this incredibly sad and tragic death and use that knowledge to improve its systems. My hope is that they seize those opportunities so this heartbreaking loss of life leads to system improvements which will save the lives of future patients.

Unfortunately, I am not encouraged that the potential for improvement will be realized after I read Vanderbilt’s official statement once the reason for this patient’s death became known. The statement blames staff for bypassing safety mechanisms, and Vanderbilt dealt with it by taking “appropriate personnel actions.” In addition to making me believe Vanderbilt will squander its learning opportunities, the statement strengthens the blame culture in our industry. There is no mention of how its systems, policies, and procedures failed the staff that they blamed, or that there are opportunities to improve mechanical and procedural safeguards.

The CMS Statement of Deficiencies report also states Vanderbilt fired the nurse involved, then sent her to counseling. The report mentions that this nurse was in a “help all” position that didn’t have a job description or formal training. She was also assigned an orientee that day to train. The report clarifies that the policies to observe patients after administering medication did not include how frequently and in what manner that observation had to be carried out or how easy it is to bypass the safety mechanism on the Automatic Dispensing Cabinet for high-risk medications.

When your only safeguard against accidents is people, mistakes will happen that lead to tragic results. The potential for mistakes increases potentially when staff are overwhelmed and in high pressure situations like hospital caregivers face everyday. In addition to potentially missing the real lessons to learn, Vanderbilt tried to hide the fact that the medication error directly resulted in the patient’s death. They didn’t report the error to the medical examiner’s office even though Vanderbilt staff knew about the error the day before the patient expired. They also decided not to report the medication error to the Tennessee Department of Health as mandated because it led to a patient’s death.

If Vanderbilt does indeed miss its lessons learned, we can all still learn from their mistakes. We can analyze our own operations and implement corrective actions proactively so we don’t see the same tragic outcomes. If we don’t, this tragedy will be compounded. Encourage your organization to get past blame and bias so you focus on improving systems instead of disciplining people when they make mistakes. Your staff needs systems that support them and the work they do. What they don’t need is the overwhelming pressure that comes with knowing that if they make a mistake, there isn’t a safeguard to catch that mistake from leading to patient harm or the loss of their job.  Feel free to contact me at marcus.miller@taproot.com to learn if TapRooT® is the right solution for your organization. To read more about Vanderbilt’s Medication Error, follow this link to the Tennessean.  https://www.tennessean.com/story/money/2018/12/04/vanderbilt-hospital-death-vumc-nurse-error-patient/2204869002/

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Patient Safety & Healthcare
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