Regulators from the Centers for Medicare and Medicaid Services, or CMS, removed the "Immediate Jeopardy" status for Ascension Saint Thomas Midtown Sept. 16, after hospital leaders worked for weeks to correct systemic problems identified after a medication error that left two patients paralyzed and two others seriously injured.
Glenda Dorton, an avid gardener from Centerville, is one of the patients who was paralyzed as a result of a medication mix-up in the hospital's pharmacy, her daughter Kristina Dorton said. Hospital workers erroneously provided the anesthesiologist with syringes of potassium, which was injected into the spinal fluid of four patients undergoing joint replacements. Safety protocols designed to catch a mistake were not followed
in the pharmacy, state regulators reported after inspections.
The hospital initially struggled to make adequate improvements to ensure such a mistake would not happen again, which led to CMS's "Immediate Jeopardy" status. The finding is CMS's most serious, indicating patients could be in danger.
Ascension has not responded to questions from reporters. But hospital officials provided an update Sept. 16, noting the medical center remains an active participant in the Medicare program and that the corrective action "establishes an ongoing framework for demonstrating continued improvement in coordination with regulatory agencies."
Ascension officials said: "At all times, our hospitals will remain open, operational, eligible for Medicare and fully committed to serving the Middle Tennessee community."
Unlike some Nashville hospitals, Ascension Midtown medical center's pharmacy compounded its own drugs, with labels for an anesthetic resembling those used for potassium, according to a state report by evaluators with the Tennessee Department of Health. The hospital had to change the way the medicines are labeled, stored, prepared and verified before CMS removed the "Immediate Jeopardy" status.
During an August interview, Kristina Dorton discussed how the error happened. "We were told that it came directly from the pharmacy. I want to be very clear that this was not the doctor's fault. This was not the anesthesiologist's fault. This was not the care team's fault."
Ascension has not released details about the harm done to the four patients, citing patient privacy laws. According to the state report, two were paralyzed, one was placed on a machine that aids the heart and lungs and the other patient is continuing to receive medical care.
Ascension noted that its leaders are continuing to work with an independent quality consultant "to guide and verify the full scope of our corrective actions and process enhancements."
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 Saint Thomas Midtown has most serious safety finding lifted
