Four patients at Ascension Saint Thomas Hospital Midtown in Nashville suffered serious injuries after receiving the wrong spinally injected medication during joint replacement surgeries.
A Tennessee Health Facilities Commission investigation found that the error resulted from multiple breakdowns in the hospital’s medication preparation and safety procedures. Regulators initially placed the hospital under “immediate jeopardy,” a federal designation used when safety deficiencies pose serious risk of harm or death to patients.
Potassium Phosphate
All four patients were supposed to receive mepivacaine, a local anesthetic used to prevent pain. Instead, they were injected with potassium phosphate, a medication that can cause serious harm if administered incorrectly and requires additional safety precautions. The syringes were prepared the previous day in the hospital’s pharmacy and incorrectly labeled as mepivacaine.
Following the injections, all four patients required a higher level of care. One briefly went into cardiac arrest during surgery. Three experienced significant neurological injuries, including paralysis and loss of sensation below the abdomen. Another required ECMO, a form of life support that temporarily performs the work of the heart and lungs. All four continue to experience neurological problems and paralysis.
Failed Safeguards
Investigators traced the error to multiple failures involving the hospital pharmacy’s medication preparation process. Surveillance footage showed a pharmacy technician selecting potassium phosphate while preparing a batch that was supposed to contain mepivacaine. Both medications come in similar-looking vials, with names beginning with the letter “P.”
A second technician then filled five syringes, labeling them as mepivacaine without visually checking the vials. Investigators also discovered that pharmacy software allowed staff to bypass barcode scanning and enter medication information manually, preventing safeguards within the system from identifying the wrong drug. The pharmacist did not detect the error during final verification either.
Investigators also found that six syringes had been ordered, but only five were prepared, a yet unresolved discrepancy.
Delayed Treatment
Regulators also identified problems with the hospital’s response once the patients received the wrong medication. All were transferred to another Ascension hospital facility for spinal lavage, a procedure to flush fluid from around the spinal cord in an effort to remove the medication. Ascension Midtown has no established protocol for treating this type of medication error.
Regulators Cite Serious Safety Concerns
The initial investigation found serious deficiencies involving the hospital’s pharmacy, surgical services, and leadership oversight. Ascension submitted several plans outlining how it would correct the problems. The first three were rejected. The hospital ultimately submitted five plans before regulators accepted its corrective measures.
Ascension has since separated high-alert medications into specially marked storage areas, strengthened barcode and verification requirements, added independent pharmacist checks for spinal medications, and brought in outside quality experts to review safety improvements.
Regulators have since lifted the immediate jeopardy designation. However, a follow-up investigation found several areas of non-compliance, including pharmaceutical oversight and the investigation and follow-up of serious adverse events.
The Tennessee Bureau of Investigation has also opened an investigation into the incident.
When Are Medication Errors Medical Malpractice?
Hospitals and medical professionals have safety procedures designed to keep medication mistakes from reaching patients. When those safeguards break down and a patient is seriously harmed, the situation may be medical malpractice. Attorneys typically examine whether providers:
- Followed accepted medication safety procedures
- Properly identified and labeled medications
- Responded appropriately to warnings or discrepancies
- Provided timely treatment after discovering the error
When hospitals fail to follow medication preparation, labeling, verification, and administration safeguards, patients can suffer catastrophic injuries, and those failures may be grounds for a medical malpractice claim.
Washington, D.C., Medical Malpractice Lawyers at the Law Offices of Dr. Michael M. Wilson, M.D., J.D. & Associates Help Clients Hold Negligent Medical Providers Accountable
The Law Offices of Dr. Michael M. Wilson, M.D., J.D. & Associates is a premier medical malpractice firm. If you or a loved one has suffered medical harm, call us at 202-223-4488 or contact us online to schedule a free consultation. We have offices in Washington, D.C., and also serve clients in Northern Virginia and Maryland.
