Vanderbilt case

Vanderbilt case

Vanderbilt case

Watch the following video about the Vanderbilt nurse:

Nurse Arrested for Fatal Error 


  • Define workforce issues. (cite)
  • Look in the National Steering Committee for Patient Safety. Safer Together: A National Action Plan to Advance Patient Safety white paper) may be directly linked to an event (staffing and workplace safety), or indirectly linked (wellness and burnout). The indirect links predisposes caregivers to errors. You can also Look at the Aiken, Needleman, and the Rogers articles.  The Begley white paper also has a lot of information as well. Workforce issues is not the information in your cause analysis. In your paper, list the direct and indirect work force issues


  • Identify any workforce issues found in the Vanderbilt case. (cite)


  • Briefly explain the Wisconsin case. (cite)


  • Contrast the workforce issues found in the Wisconsin case with Vanderbilt case, in particular using the Denham article and the CMS report. (cite)


  • The Vanderbilt case, which was well-publicized, happened more than 10 years after the Wisconsin case. Were lessons learned?


Useful Resources:

National Steering Committee for Patient Safety. Safer Together: A National Action Plan to Advance Patient Safety. (Links to an external site.) Boston, Massachusetts: Institute for Healthcare Improvement; 2020.

Denham, C.R. (2010). The missing safe practice.  Joint Commission Journal of Quality and Safety, 36, 149-150.  PMID: 20402370 doi: 10.1016/s1553-7250(10)36025-9.

CMS report:

Aiken, L.H., Clarke, S.P., Sloane, D. M., Sochalski, J., & Silber, J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction.  JAMA, 288, 1987-1993.  PMID: 12387650  doi: 10.1001/jama.288.16.1987.

Needleman, J., Buerhaus, P., Pankratz, S., Leibson, C.L., Stevens, S.R., & Harris, M. (2011). Nursing staffing and inpatient hospital mortality. The New England Journal of Medicine, 364, 1037-45.  PMID: 21410372  doi: 10.1056/NEJMsa1001025.

Rogers, A.E., Hwang, W., Scott, L.D., Aiken, L.H., & Dinges, D.F. (2003). The working hours of hospital staff nurses and patient safety.  Health Affairs, 23, 202-212.  PMID: 15318582 (Links to an external site.) PMID: 15318582

Begley, R., Cipriano, P.F., & Nelson, T. (2020).  The business of caring:  Promoting optimal allocation of nursing resources.  ANA, AONL, hfma.