A devastating medication error that impacted four surgical patients at Ascension Saint Thomas Midtown in Nashville, Tenn., received a large amount of mainstream media attention over the last week—reminding perioperative leaders of the critical importance of medication safety protocols.
CBS News affiliate WTVF-TV reported that “at least four people went to Ascension Saint Thomas Midtown in Nashville for joint replacement surgeries, and a drug mix-up led to things going horribly wrong in the operating room.” All four joint replacement surgeries were outpatient procedures, according to the TV station’s reporting.
The TV station spoke with the family of woman who was at the hospital for a knee replacement and is now “permanently paralyzed from the chest down” after she was supposed to receive an epidural but the wrong medication was injected. The patient remains in the ICU, according to the family, and WTVF reported that at least one of the other three affected patients was also “left paralyzed.”
WTVF reported that it was told the errors originated in the hospital’s pharmacy, where potassium was loaded in the syringes used in the procedures rather than bupivacaine. The TV station noted that “potassium is one of the drugs often used in lethal injections because it stops the heart.”
According to WTVF, Ascension Saint Thomas Midtown stated that it immediately reported the event to state regulators, who told the TV station that “they are investigating.”
In a statement, the hospital’s president and CEO, Shubhada Jagasia, MD, told the TV station that “our hearts are with the four patients and their families impacted by this event. On behalf of our leadership and care teams, I am deeply sorry for the harm caused to our patients. We have met directly with each of the families to express our deep support, connected them with spiritual care teams, and ensured they have access to all appropriate resources and ongoing care needed.”
Dr. Jagasia added that the hospital launched a “thorough investigation” on the day of the events, has identified the cause, and has “implemented corrective safeguards.”
