Report Details a Serious Hospital Pharmacy Error
An 80-page report from the Tennessee Health Facilities Commission has added new details about a medication error at Ascension Saint Thomas Midtown Hospital in Nashville. According to the report and local coverage from WKRN, four patients were affected on August 14 after they were given the wrong medication before surgery. At least two patients are paralyzed, and one patient was placed on a ventilator. The patients were reportedly given potassium instead of an anesthetic. CBS reported that too much potassium given too quickly can stop a person’s heart. The Tennessee Bureau of Investigation is now involved. The hospital apologized, saying its “hearts remain entirely with the four patients and families impacted” and that it extends “deepest apologies for the harm caused.” Given the suffering described, this is not a moment for clever spin or public relations fog. It is a moment for answers.
How the Syringes Were Reportedly Swapped
Investigators found that five syringes meant to contain Mepivacaine 2%, an anesthetic, were instead filled with potassium phosphate the day before surgery. The error moved through preparation, verification, and dispensing, even though three pharmacy technicians and one pharmacist were involved. According to WKRN’s summary of the report, Pharmacy Technician #1 first retrieved one vial of the anesthetic, then returned to another storage bin and grabbed a vial of potassium phosphate. The wrong medication was then taken to the mixing room, where Pharmacy Technician #2 filled five surgical syringes with the potassium. Those syringes were labeled as Mepivacaine and sent to the pharmacist shortly before 11 a.m. on August 13. The report says the pharmacist reviewed the syringes but did not physically compare the medication with the computer record. The verification and approval took 29 seconds, according to the report. The syringes were then sent from the hospital’s in-house pharmacy for use on patients the next day.
Technicians’ Statements Raise More Questions
The report also includes statements from the pharmacy technicians involved. Pharmacy Technician #1 told investigators last week that she “could not say for sure if the vial was Mepivacaine or Potassium Phosphate” and that “she wished she had looked more closely at the vials.” Pharmacy Technician #2 said she was being supervised by Pharmacy Technician #3 because she was near the end of her probationary period and had never mixed Mepivacaine 2%. The report says Pharmacy Technician #3 worked at the hospital for the rest of the day after the surgical patients went into cardiac arrest, even though she was involved in the medication process under review. Pharmacy Technician #1 was placed on leave on August 14 pending investigation and said no one from the facility had reached out to him. When asked about the drug mix-up, he said he “did not know if he needed to talk to the survey team without an attorney.” These details point to system failures that did not stop at one bad grab from a shelf.
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Families Seek Counsel as Investigation Continues
The report describes severe pain and suffering after the wrong medication was administered. No lawsuits have been filed against Ascension Saint Thomas Hospital Midtown, according to the source article, but the families of the victims are consulting with attorneys. The hospital has apologized, and investigators have laid out a chain of events that included storage, preparation, labeling, and verification failures. The key question now is how a high-risk medication could be confused with an anesthetic, placed into surgical syringes, labeled incorrectly, approved, and delivered for patient use. Hospitals have layers of checks for a reason. When those layers all fail, patients and families pay the price in the most personal way possible.
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