Ascension Saint Thomas said a Nashville hospital drug mix-up at its Midtown hospital sent four joint replacement patients potassium phosphate instead of mepivacaine on Friday, Aug. 14. The hospital said the error happened inside the pharmacy at Ascension Saint Thomas Hospital Midtown and that the four patients received immediate medical care after adverse health reactions.
Glenda Dorton’s family said she was one of the four patients. They said the 72-year-old went to Saint Thomas Midtown for a routine knee replacement and was supposed to receive an epidural anesthetic before surgery.
Ascension Saint Thomas Hospital Midtown
Ascension Saint Thomas said it later issued a statement spelling out the drug swap after initially saying only that four patients had been harmed. The hospital said a comprehensive review found no other patients were affected.
The statement also said hospital leadership self-reported the incident to state regulators after identifying it on Aug. 14. The hospital said it has since put in place physical, technological and clinical safeguards aimed at preventing a similar medication error. It also said it is working with state and federal officials and has brought in independent, third-party quality experts to review and validate its mitigation plans.
Glenda Dorton
Her family said the problem did not end at the operating room. They said Dorton woke up after surgery unable to feel or move from the sternum down and was later told she has T-6 paralysis.
Ascension Saint Thomas said, “The four patients experienced adverse health reactions and received immediate medical care.” The hospital also said, “Our hearts remain entirely with the four patients and families impacted by the recent event at Ascension Saint Thomas Hospital Midtown.”
For families and patients, the immediate question now is not whether the mix-up was real; the hospital has said it was. The open issue is how the pharmacy process let potassium phosphate reach patients who were supposed to get mepivacaine, and whether the added safeguards will block a repeat.
