What happened at Ascension Saint Thomas Midtown?

According to an August 21 statement from Ascension Saint Thomas, an error in the hospital pharmacy affected four patients undergoing joint replacement procedures at its Midtown campus.

The hospital stated that the patients were supposed to receive mepivacaine, a local anesthetic, but instead received potassium phosphate. All four experienced adverse health reactions and required immediate medical treatment. Ascension said its subsequent review found that no additional patients were affected.

One of those patients was Glenda Dorton, 72, who underwent knee replacement surgery. Her family has reported that she lost movement and sensation from approximately the chest down following the medication error.

The distinction between the medications matters. FDA prescribing information identifies potassium phosphate injection as a medication intended for intravenous administration after appropriate dilution or preparation, including for treatment of low phosphate levels and use in parenteral nutrition. The FDA labeling warns that improper or overly rapid intravenous administration can cause severe complications, including cardiac arrest, arrhythmias, seizures, and dangerous electrolyte abnormalities.

The Institute for Safe Medication Practices also includes potassium phosphate injection on its list of high-alert medications, a designation used for drugs that carry a heightened risk of causing significant patient harm when used incorrectly.

Four affected patients raise questions beyond a single medication mistake

When a patient receives the wrong drug, investigators need to determine how that error occurred.

When four patients undergoing similar procedures receive the same incorrect medication, the investigation becomes broader.

Important questions may include:

• How was potassium phosphate selected instead of mepivacaine?
• Where were the two medications stored?
• How were medications labeled and prepared in the pharmacy?
• What barcode or electronic medication-verification systems were in place?
• Did any warning appear when the medication was scanned?
• What independent verification was required before medication intended for spinal administration reached a patient?
• Did pharmacy staffing, workflow, supervision, or communication contribute to the error?
• At what point could the error reasonably have been detected before the medication reached the patients?

Those questions are particularly significant because Ascension says it changed several pharmacy procedures following the event.

The hospital says it has now separated high-alert medications into distinctly marked storage locations, instituted a mandatory stop-and-escalation procedure when a spinal medication produces a scanning alert, and required a second trained pharmacist to independently verify spinal medications before final approval.

Those changes do not, by themselves, establish what caused the August 14 error. They do identify several areas investigators will likely scrutinize when determining how the wrong medication reached four patients.

Tennessee authorities are investigating

Ascension says hospital leadership reported the medication error to state regulators on August 14.

The Tennessee Bureau of Investigation has also opened an investigation after receiving information from the Tennessee Healthcare Facilities Commission. According to reporting from Becker’s Hospital Review, the Healthcare Facilities Commission notified the TBI on the evening of August 14.

Ascension has separately retained independent quality experts to review its response and the additional safeguards implemented after the event.

The investigations may provide important information about how the pharmacy error occurred, which safeguards failed or were bypassed, and whether additional action is warranted.

When can a hospital medication error become medical malpractice?

A medication error can support a medical malpractice claim when a healthcare provider fails to meet the applicable standard of care, and that failure causes injury.

Wrong-drug cases can involve negligence at several points in the medication chain, including selection, preparation, dispensing, labeling, verification, storage, administration, and monitoring.

Responsibility may extend beyond the individual who ultimately administered the drug. Depending on the evidence, a catastrophic medication-error case may require examination of the conduct and systems involving pharmacists, nurses, physicians, anesthesia professionals, hospital administrators, and the healthcare facility itself.

McEldrew Purtell handles complex pharmacy and medication error cases involving serious injury and death. These cases require more than proving that the wrong medication reached the patient. The investigation must establish where the process failed, who was responsible, whether appropriate safeguards should have prevented the error, and how the medication caused the patient’s injuries.

The firm also handles broader medical and surgical error claims, as well as catastrophic medical malpractice cases.

Evidence can be critical after a catastrophic medication error

Medication-error cases often depend on records that go well beyond the ordinary medical chart.

A thorough investigation may require preservation and analysis of:

• pharmacy dispensing and preparation records;
• medication administration records;
• barcode scanning and electronic alert logs;
• anesthesia records;
• medication packaging, labels, lot information, and remaining product;
• pharmacy inventory and storage records;
• electronic health record audit trails;
• internal incident and safety reports;
• staffing and shift information;
• hospital medication-management policies;
• communications among pharmacy, nursing, anesthesia, and surgical staff; and
• subsequent diagnostic testing documenting neurological or other injuries.

When paralysis or another permanent neurological injury follows a medication error, medical causation can also require experts in pharmacy practice, anesthesiology, neurology, neuroradiology, rehabilitation, and other specialties.

The central question is not simply whether somebody “gave the wrong drug.” It is how multiple safeguards failed to prevent the medication from reaching the patient and whether those failures caused catastrophic harm.

Patients and families affected by serious medication errors deserve answers about how the mistake occurred and whether it could have been prevented. McEldrew Purtell investigates catastrophic medical malpractice cases involving pharmacy errors, hospital negligence, paralysis, neurological injury, and wrongful death.

Individuals and families affected by a serious medication error, as well as attorneys evaluating a potential referral or co-counsel matter, can contact McEldrew Purtell for a confidential case evaluation.