State investigators found pharmacy and oversight failures after joint-replacement patients received potassium phosphate instead of the intended anesthetic.
NASHVILLE, Tenn. — State regulators found multiple safety failures at Ascension Saint Thomas Hospital Midtown after four joint-replacement patients were injected with potassium phosphate instead of the anesthetic mepivacaine, an Aug. 14 medication error that left patients with severe neurologic and cardiopulmonary complications.
The findings, detailed in an 80-page regulatory report released this week, provide the clearest account yet of how the medication error occurred and how the hospital responded. Investigators found problems involving pharmacy procedures, surgical services and hospital oversight, and cited three areas of immediate jeopardy, a regulatory finding used when conditions put patients at risk of serious harm. As of Aug. 21, one affected patient remained on extracorporeal membrane oxygenation, or ECMO, for heart and lung support, while three continued to have significant neurologic impairment in their lower bodies.
The error began Aug. 13, when five syringes intended to contain mepivacaine for spinal administration during elective orthopedic procedures were instead prepared with potassium phosphate, according to the state findings. Four of the syringes were administered to patients the next day. Ascension later clarified that seven patients were on the joint-replacement surgery schedule Aug. 14 and that four received the incorrect medication. The fifth incorrectly prepared syringe was not administered.
Investigators concluded that the mistake passed through several stages without being detected. The regulatory findings said three pharmacy technicians and a pharmacist were involved in the medication preparation, verification and dispensing process. Investigators also raised concerns about training, supervision and the storage of high-alert medications. NewsChannel 5 reported that one technician was relatively new and that management had raised concerns shortly before the incident about the employee’s understanding of medication terminology and labels.
The report also described broader system problems rather than a single mistaken selection of a drug. Investigators said hospital processes allowed pharmacy-system safeguards to be overridden and found inadequate pharmacist oversight during preparation. They also reported that potassium products remained stored with other medications during portions of the investigation instead of being separated and clearly identified as a high-alert medication. Regulators concluded that personnel failures and underlying system failures combined to create conditions in which the error could reach patients.
All four patients experienced serious complications and were transferred to a higher level of care, according to the report. One patient went into cardiac arrest after receiving the medication and was later reported to have paralysis. Another patient was able to move her toes but could not lift her legs, according to accounts of the state findings. A fourth patient required ECMO support. The report’s descriptions reflect patient conditions during the regulatory review and do not necessarily represent their current medical status.
One of the patients has been publicly identified by her family as 72-year-old Glenda Dorton of Centerville, who entered the hospital Aug. 14 for knee replacement surgery. Her family said she was left paralyzed from around the chest or midsection downward after receiving the wrong medication. Dorton’s relatives later said she would be transferred to Shirley Ryan AbilityLab in Chicago for about six weeks of intensive rehabilitation. They described her recovery as long and uncertain while saying she had already begun working closely with rehabilitation therapists.
Investigators also scrutinized the hospital’s response after the patients began showing severe symptoms. The state report cited delays and shortcomings in the treatment response and found failures in how the hospital handled staff and corrective measures after the incident. NewsChannel 5 reported that several corrective-action plans submitted by the hospital during the survey were deemed unacceptable by regulators because they did not provide enough assurance that the identified safety problems had been resolved. When inspectors concluded their on-site work Aug. 21, an acceptable plan had not yet been confirmed.
Ascension Saint Thomas has apologized to the four patients and their families and acknowledged that the error originated in its pharmacy. The hospital said the patients mistakenly received potassium phosphate instead of mepivacaine and experienced adverse health reactions. It said a review found that no other patients were affected and that hospital leadership self-reported the event to state regulators on Aug. 14. Ascension has since announced additional safeguards, including separating high-alert medications, requiring escalation when a spinal-medication scanning alert occurs and adding an independent second-pharmacist verification step to spinal medication workflows.
After receiving the state and federal survey findings, Ascension said Aug. 27 that it took the findings seriously and was continuing to cooperate with regulators. The hospital also said it had brought in independent quality experts to review its corrective measures. Ascension disputed some media interpretations of the report but reiterated that only four of the seven patients scheduled for joint-replacement procedures that day received the incorrect medication.
The Tennessee Bureau of Investigation is separately examining the incident after receiving information from the Tennessee Health Facilities Commission. The TBI has described its investigation as active and ongoing. No public finding has established that the medication error was intentional, and authorities have not announced criminal charges. Regulatory review of the hospital’s corrective actions also remains ongoing, while Dorton and other affected patients continue treatment and rehabilitation.