The Tennessee Health Facilities Commission has released an 80-page report that details its investigation into the medication errors at Nashville hospital Ascension Saint Thomas Midtown that impacted four surgical patients. It determined the mistakes were primarily caused by human error.
According to local TV station WKRN, “at least four out of seven patients scheduled for surgery” on Aug. 14 received potassium phosphate instead of mepivacaine 2%. It states that, according to the commission’s investigation, “one patient remained on extra corporeal membrane oxygenation…and three patients continued to experience significant lower-extremity neurologic impairment, including paralysis and loss of sensation extending from approximately the mid-abdominal region downward.”
“Investigators determined five syringes of incorrect medication for nerve blocks were prepared the day before the surgeries,” reports WKRN. “The error was not detected during the preparation, verification and dispensation process despite the oversight of three pharmacy technicians and one pharmacist. Officials reviewed four video surveillance angles of three pharmacy areas involved in the error to determine the sequence of events.”
Click here to read the Tennessee Health Facilities Commission’s full report on the incident.
