Nashville — Vanderbilt University Medical Center was not upfront with the county medical examiner about a deadly medication error when a patient died after being accidentally injected with a paralyzing anesthetic, according to a recent federal investigation report.
The patient, who has not been publicly identified, died last December after a nurse intended to give them a routine sedative but instead injected vecuronium, a powerful drug used to keep patients still during surgery.
Vecuronium is also part of the deadly three-drug cocktail used to execute death row convicts in Tennessee and some other states.
In this case, the drug appears to have caused the patient, who was otherwise stable, to lose consciousness, suffer cardiac arrest and ultimately be left brain dead. The patient died one day later after being taken off of a breathing machine.
But not all of that information was given to the Davidson County Medical Examiner, who is supposed to investigate all unusual deaths in Nashville, according to an investigation report from the Centers for Medicare and Medicaid Services.
Instead, it appears that a Vanderbilt doctor told the medical examiner’s office that the patient died from bleeding and that any medication errors were purely “hearsay,” according to the investigation report. This led the medical examiner’s office to decline to investigate because staff believed the patient died a natural death that was outside their investigatory jurisdiction.
When questioned about the discrepancy on Thursday, Vanderbilt spokesman John Howser did not say specifically if hospital staff ever informed the medical examiner about the vecuronium or if the medication error was ever described as “hearsay.”
Instead, Howser stressed that the patient's death was reported to the medical examiner within 40 minutes, before there was a “definitive conclusion” about the cause of death. He did not address the fact that the medication error had occurred the preceding day.
“The report to the Medical Examiner’s office was made promptly and in good faith and was based on the information that could be confirmed at the time of the report,” Howser wrote in an email.
Patient was improving before nurse's error
The medication error occurred on Dec. 26 while the patient was being treated at Vanderbilt for a subdermal hematoma – or bleeding in the brain – that was causing a headache and loss of vision. Despite these symptoms, the patient was alert, awake and in improving condition, according to the federal investigation report.
The patient was then taken to Vanderbilt’s radiology department to receive a full body scan, which involves laying inside a large tube-like machine. Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication.
A nurse then went to fill this prescription from one of the hospital’s electronic prescribing cabinets, which allow staff to search for medicines by name through a computer system. The nurse could not find the Versed, so she triggered an “override” feature that unlocks more powerful medications, according to the investigation report.
The nurse then typed the first two letters in the drug’s name – “VE” – into the cabinet computer and selected the first medicine suggested by the machine, not realizing it was vecuronium, not Versed.
The drug was then given to the patient, who was then put into the scanning machine before anyone realized a medication mistake had been made. The patient was then left alone to be scanned for as long as 30 minutes, according to the investigation report, before someone realized the patient was not breathing and medical staff began CPR.
It was at this point, the report states, that the medication error was discovered. A second nurse found a baggie that was left over from the medication that was given to the patient.
“Is this the med you gave (the patient?)” the second nurse asked the first nurse, showing her the baggie, according to the report. “This isn't Versed. It's vecuronium."
Doctors were then informed about the error. The patient was treated in the hospital for another day before the patient was determined to be beyond help and was taken off a breathing machine. Doctors then reported the death to medical examiner’s office.
Deadly error described as 'hearsay'
Despite the circumstances of this death, that patient’s medical records do not include any documentation of the medical examiner’s office being informed about the medication error, according to the federal investigation report.
Additionally, the Vanderbilt doctor who reported the death to the medical examiner told investigators that they could not remember if they had mentioned the error.
When questioned about this oversight by federal investigators, Vanderbilt officials said they were uncertain if the medication error had anything to do with the death at all.
“We don’t know,” an unidentified Vanderbilt official told investigators, according to the report. “(The patient) got such a small dose, and he/she was anxious about the test, so we can’t say it contributed to his/her demise.”
The medical examiner’s office, however, saw it differently. During a separate interview with federal officials, a medical examiner’s official said Vanderbilt should have informed him about any error involving a paralyzing medicine.
Instead, the reporting doctor attributed the death to bleeding in the patient’s brain and vecuronium was never mentioned, the official told federal officials.
“We released jurisdiction because there was an MRI that confirmed the bleed,” said the medical examiner's official, who is quoted in the federal report but not named. “(A Vanderbilt doctor) stated maybe there was a medication error, but that was hearsay, nothing has been documented. Since there was no documentation and he/she said it was just hearsay, we didn't see any red flags..."
The Tennessean was unable to independently confirm what details about the patient’s death are recorded in the files of the Davidson County Medical Examiner’s Office because staff could only release records about the patient’s death if he could be identified by name. The patient’s identify has been kept strictly confidential in all documents that have been made public.
In addition to raising concerns about what was reported to the medical examiner, Vanderbilt's patient death resulted in the hospital's Medicare reimbursement status to be jeopardized earlier this month.
The Centers of Medicare and Medicaid Services confirmed that it may discontinue Medicare payments to Vanderbilt if it did not receive assurances that the hospital had taken steps to prevent similar errors in the future, then announced on Thursday afternoon that it had accepted Vanderbilt's corrective plan and that the hospital's reimbursements were no longer in jeopardy.
Brett Kelman is the health care reporter for The Tennessean. He can be reached at 615-259-8287 or at brett.kelman@tennessean.com. Follow him on Twitter at @brettkelman.