Intake Number: TN00045852

Printed: 12/10/2018

INTAKE INFORMATION

Due Date: 10/05/2018

Facility ID: TNP53127

Priority: IJ

Provider Number: 440039
State Region: TNW

LQWUD990RQP4TZUDD3
PROVIDER INFORMATION:
Name: VANDERBILT UNIVERSITY MEDICAL CENTER

License #: 53127
Type: HOSP-ACU

Address: 1211 MEDICAL CENTER DRIVE
City/State/Zip/County: NASHVILLE, TN, 37232, DAVIDSON

Medicaid #:

Telephone: (615) 322-3454

Administrator: C. WRIGHT PINSON

INTAKE INFORMATION:
Intake Number: TN00045852

Taken by - Staff:

(b)(6)

Location Received: STATE AGENCY CENTRAL OFFICE

Received Start: 10/03/2018

At 10:20

Received End: 10/03/2018

At 10:20

Received by: In Person

Intake Type: Complaint

State Complaint ID:

Intake Subtype: Federal COPs, CFCs, RFPs, EMTALA, CLIA

CIS Number:
External Control #:

SA Contact:

(b)(6), (b)(7)c

RO Contact:

Responsible Team: STATE AGENCY WEST TENNESSEE
Source: Anonymous

COMPLAINANTS:
Name

Address

Phone

EMail

Not Applicable
Link ID:

(b)(7)d

Confidentiality Requested :

Y

INTAKE DETAIL:
Date of Alleged Event:

Time:

Shift:

Standard Notes: An anonymous complainant reports the following:

(b)(6), (b)(7)c
On December 26, 2017
administered an incorrect medication to (b)(6), (b)(7)c , a patient at
Vanderbilt University Medical Center when she was awaiting a PET scan.
(b)(6), (b)(7)c was "the help all nurse" for the Neuro Intensive Care Unit, stepdown and the 6th floor nursing units.
She was orienting a new registered nurse
The stepdown nurse asks
to
(b)(6), (b)(7)c
(b)(6), (b)(7)c
give
some versed for anxiety before her PET scan.
(b)(6), (b)(7)c
(b)(6), (b)(7)cremoved the incorrect drug from the Pyxis, did not read the label and accidentally administered
vecuronium instead of versed.
(b)(6), (b)(7)c was in the PET scan for 20 minutes. When the patient came out of the PET scan unit, she was
unresponsive, was resuscitated and passed away in the Neuro Intensive Care Unit later that day.
During an investigation with Board of Investigations(b)(6), (b)(7)cstated she administered the incorrect medication to
(b)(6), (b)(7)c before the patient had the PET scan and she didn't read the label after she pulled the incorrect drug
from the Pyxis. She reported the order had not crossed over to the Pyxis and when she typed in Versed, she
accidentally picked the first medication that come up on the screen. She was in a busy area without a "no talk zone"
designated sign. She further stated, there was no place to scan the medication before giving it to the patient. She
gave the medication IV and flushed after.
It is reported the nurse did not check the Dr. orders, follow the 5 rights of medication administration, administered a
drug outside her scope of practice, and failed to properly monitor the patient after administering a medication.
The patient suffered an anoxic brain syndrome as a result of being given the vecuronium and died.
(b)(6), (b)(7)c was terminated from VUMC on January 3, 2018.
Vanderbilt University Medical Center did not report this sentinel event via IRS to the SSA.

*****Please see attached Investigative Report from Health Related Boards*****
Extended RO Notes:
Extended CO Notes:

ALLEGATIONS:
Category: Accidents
Sub-category:
Seriousness:

Details:
ACTS: Intake.rpt 10/99

Page 1 of 3

 Intake Number: TN00045852

Printed: 12/10/2018

INTAKE INFORMATION

Due Date: 10/05/2018

Facility ID: TNP53127

Priority: IJ

Provider Number: 440039
State Region: TNW

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Category: Death - General
Sub-category:
Seriousness:

Details:

See Above

Category: Nursing Services
Sub-category:
Seriousness:

Details:

See Above

Category: Quality of Care/Treatment
Sub-category:
Seriousness:

Details:

See Above

CONTACTS:
Possible Witness

tor
LIST
Possible Witness
Possible Witness
Possible Witness

ND PI.
Possible Witness
Possible Witness
Possible Witness

(b)(6), (b)(7)c

(b)(6), (b)(7)c

GIST
Possible Witness
EMENT Witness
Possible
Possible Witness

NER OFFICE
Possible Witness

Possible Witness
Possible Witness

DEEMED/RO APPROVAL INFORMATION:
Ro Request for Approval: 10/03/2018

RO Approval Date: 10/03/2018

SURVEY INFORMATION:
Event ID

Start Date

Exit Date

NVYT11

10/30/18

11/08/18

Team Members

(b)(6), (b)(7)c

ACTIVITIES:
Type

Sent

Due

Completed

Schedule Onsite Visit

10/30/2018

10/30/2018

10/31/2018

Letter to Provider/Supplier

11/26/2018

12/06/2018

ACTS: Intake.rpt 10/99

Responsible Staff Member

(b)(6), (b)(7)c

Page 2 of 3

 Intake Number: TN00045852

Printed: 12/10/2018
Due Date: 10/05/2018

INTAKE INFORMATION

Facility ID: TNP53127
Provider Number: 440039

Priority: IJ

State Region: TNW

LQWUD990RQP4TZUDD3
Reason for Restraint:
Cause of Death:
END OF INTAKE INFORMATION

ACTS: Intake.rpt 10/99

Page 3 of 3