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Vanderbilt Comments on Patient Error, CMS Corrective Action Plan


 
Following a medication error last December that resulted in a patient death, Vanderbilt University Medical Center faced scrutiny by CMS, which could have potentially impacted Medicare reimbursement. However, on Nov. 29, the federal agency accepted a corrective action plan submitted by the city's academic medical center.
John Howser, chief communications officer for VUMC, released the following statement regarding the incident: "VUMC was notified of an adverse finding by the Tennessee Department of Health after an on-site survey involving a patient who died in December 2017 following a medication error. 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. 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 that any remaining concerns are fully resolved within the specified time frame."
According to a CMS report, in December 2017, a nurse went to the digital medication cabinet to pull midazolam - brand name Versed. When typing in 'VE' didn't pull up the drug, the nurse manually overrode the system, inadvertently dispensing vecuronium, a powerful anesthetic. Complicating matters, routine observation procedures weren't followed after dispensing the medication so it was estimated 30 minutes or more passed before staff realized the patient had lost consciousness.
With acceptance of the corrective action plan, VUMC's Medicare reimbursement status is no longer in jeopardy.
 
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