A medication error that paralyzed one orthopedic surgery patient at Ascension Saint Thomas Hospital in Nashville Aug. 14 also significantly affected three other patients, according to a report released by the Department of Health and Human Services.
The incident centers around mislabeled syringes of medication. The intended drug was mepivacaine, which is a local anesthetic. But the mislabeled syringes actually contained potassium phosphate, which was administered intrathecally, or directly into spinal fluid, during spinal anesthesia procedures for four different patients, according to the report.
One of those patients is Glenda Dorton, 72, whose daughter-in-law said she is now paralyzed. Dorton is a physically active, avid gardener who went to the
hospital for a knee replacement.
After the incident, Ascension officials called it an "isolated medication error." But the report, released Aug. 26, found that the hospital failed to maintain adequate medication safety controls. Expert witnesses cited in the report described the situation as the result of multiple "active failures," or errors made by both humans and technology systems in the hospital, in addition to system-wide causes.
Ascension officials said once the mistake was discovered Aug. 14, they self-reported to state regulators. The new report was initiated on Aug. 16.
“Upon identifying the medication error on August 14, hospital leadership self-reported the event to regulators and implemented several changes to our pharmacy processes and safety protocols," hospital officials said in an updated statement after the report was released.
"We take the survey findings extremely seriously and are continuing to cooperate with state and federal surveyors to ensure a safe environment for our patients. We remain committed to upholding safety standards for every person who trusts us with their care."
This is a developing story. Please check back for updates.
Beth Warren covers health care and can be reached at bwarren@tennessean.com or on X at @BethWarrenCJ.
This article originally appeared on Nashville Tennessean: Ascension lacked safety controls before pharmacy mix-up: Report
