VUMC.edited.edited.docx

1 Medical Error Students Name Institution Affiliation Course Date

2 Vanderbilt University Vanderbilt university medical center is located in the Southeast of the United States. It is the largest academic medical center in the region, serving people from Tennessee and the mid- south ( Tennessean.com. 2021) . On average, the center manages two million patients every year. It provides primary care and specialized treatment to patients throughout the area. More than one thousand residents and associates train in specialized care from the institution. The school of medicine and research ranks among the best tops ten in the country. As a result, it receives funding and awards. Vanderbilt aims to improve the healthcare of individuals and communities through their exceptional competencies and caring spirit of its clientele. The Joint Commission and Gold Seal Accreditation The joint commission accredits VUMC but works independently of the medical center. It is not for profit based organization that institutes standards and credits healthcare societies and programs in the U.S. TJC is recognized nationally as a symbol of promoting equity in the health care sector (Communications, 2021) . VUMC is surveyed after every three years by the commission to ascertain its commitment to the set performance standards. The surveys are done without notice to avoid bias in the results. Vanderbilt university medical center attained the gold seal accreditation after the staff had made improvements in prominent areas that affect healthcare (Communications, 2021) . The medical Centre had a conducive environment for patient care, educated patients on disease risks, protected patients’ rights, and evaluated patients' conditions before and after treatment. Additionally, they put strategies to protect the community from infections and had a strategic plan for emergencies.

3 The Incident A medical error occurred in the hospital when a nurse mistakenly administered a paralyzing anesthetic to a patient leading to his death ( Tennessean.com. 2021). The nurse intended to inject sedatives but injected vecuronium, used in surgeries to keep patients still. The patient died a day later after losing consciousness and suffering cardiac arrest ( Tennessean.com. 2021). However, the hospital tried to save the patient's life by putting them on breathing machines, but the information was not wholly given to unusual death investigators in Nashville. Chaos rose when Vanderbilt's doctor reported that the patient died a natural death from bleeding ( CMS threatens to revoke Vanderbilt's Medicare participation after patient death 2021). The rising issues surrounding the case affected the hospital's Medicare reimbursement in the following month. Opinion on 2002 Improvements Vanderbilt implemented 2002 improvement specifics by adopting interpersonal processes like; teamwork among the health care workers, patient involvement, mindful organizing, coordination, and reporting arising concerns ( Lighter, 2011). The strategies would reduce the cases of medical errors in practice. Teamwork would ensure that the medics interact amongst themselves to develop solutions that affect them. In mindful organizing, the doctors would be careful in operations, accepting failure, simplifying interpretations, and commitment to resilience ( Lighter, 2011). Coordination would ensure medics working on the same line have good communication relationships ( Lighter, 2011). Through this, they can develop strategies to improve their results.

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4 Health care providers offer support to patients by creating rapport and making patients comfortable communicating their feelings after treatment to detect errors early enough. Manager’s Response If I were the manager of the medical unit where the medical error occurred at Vanderbilt; I would get the nurse on duty to be open on what transpired to cause the death of the patient ( Jones, Scarduzio, Mathews et al., 2019) . Factual information would make reporting and resolution process more straightforward. Additionally, it would help the investigators to conduct their examination on time without creating too much media attention and confusion. As a manager, I would reassure the nurse of their job security which might have been one reason she gave inaccurate reporting. As long as she didn't inject the patient willing fully intending to cause harm and death, it was just a medication error ( Jones, Scarduzio, Mathews et al., 2019) . Also, I would ensure that the examiner is aware of the medical center's effort to save the patient’s life by placing him in breathing machines. I would also encourage nurses to consult with doctors and team members if encountered with challenges in the line of duty and emphasize the need to be careful when prescribing medications to patients ( Jones, Scarduzio, Mathews et al., 2019) . Finally, I would apologize for the error to the nation, commission, and all team players and give condolences to the patient’s family. Quality Assurance Manager As quality assurance manager at Vanderbilt, I would seek an outline of the medical error incident. I would establish measurement parameters of how the situation was and analyze its effects on the Medical Centre, the public, and the joint commission ( Jones, Scarduzio, Mathews

5 et al., 2019) . Additionally, I would involve team members to develop ways to improve and control the occurrence of other errors in the medical practice. Afterward, I would focus on quality management and improvements in the medical Centre to ensure programs and services in the medical Centre are implemented at the highest standards and monitor policies and procedures to prevent the occurrence of medical errors ( Jones, Scarduzio, Mathews et al., 2019) .

6 References CMS threatens to revoke Vanderbilt's Medicare participation after patient death. (2021). Retrieved 16 April 2021, from https://www.modernhealthcare.com/article/20181128/NEWS/181129938 Communications, V. (2021). VUMC Reporter . Vanderbilt University. Retrieved 16 April 2021, from https://www.mc.vanderbilt.edu/reporter/index.html?ID=2445 . Tennessean.com. (2021). Retrieved 16 April 2021, from https://www.tennessean.com/story/money/2018/11/30/vanderbilt-patient-death- medication-error-medical-examiner/2155152002/ . Lighter, D. (2011). Basics of health care performance improvement: A lean Six Sigma approach . Jones & Bartlett Publishers. Jones, M., Scarduzio, J., Mathews, E., Holbrook, P., Welsh, D., Wilbur, L., ... & Ballard, J. A. (2019). Individual and team-based medical error disclosure: Dialectical tensions among health care providers. Qualitative health research , 29 (8), 10-108.

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