A Tennessee investigation found that multiple pharmacy safeguards failed before five syringes containing potassium phosphate were mislabeled as an anesthetic and sent for surgical use at Ascension Saint Thomas Midtown Hospital, where four patients were injured, at least two were left paralyzed and one required a ventilator.
By yourNEWS Media Newsroom
An 80-page state investigation has revealed how a medication error moved through several layers of a Nashville hospital pharmacy before four surgical patients were given potassium phosphate instead of an anesthetic, triggering cardiac arrests and leaving at least two patients paralyzed.
The Aug. 14 incident occurred at Ascension Saint Thomas Midtown Hospital, where the four patients received medication prepared by the hospital’s in-house pharmacy.
One patient was placed on a ventilator following the error.
The Tennessee Bureau of Investigation is now involved in the case.
According to an 80-page report on the investigation, the chain of mistakes began one day before the procedures, when five syringes that were supposed to contain Mepivacaine 2%, an anesthetic, were instead filled with potassium phosphate.
Excessive potassium administered too rapidly can cause the heart to stop, CBS reported.
The Tennessee Health Facilities Commission investigated the incident and documented failures during preparation, verification and dispensing despite the involvement of three pharmacy technicians and a pharmacist, according to WKRN.
Investigators found that Pharmacy Technician #1 initially retrieved a vial of Mepivacaine, then returned to another storage bin and instead picked up a vial of potassium phosphate.
That vial was taken into the mixing room.
Pharmacy Technician #2 then used the potassium phosphate to prepare five syringes intended for surgery.
The syringes were labeled as containing Mepivacaine and submitted to a pharmacist for verification shortly before 11 a.m. on Aug. 13.
The pharmacist reviewed the syringes but did not physically compare the medication vial with the computerized record, investigators found.
According to the report, the pharmacist spent only 29 seconds verifying and approving the medication.
The five incorrectly filled and labeled syringes then left the hospital pharmacy and were made available for use on patients the following day.
On Aug. 14, the medication was administered before surgery to four patients, who subsequently suffered severe medical emergencies, including cardiac arrest.
At least two were left paralyzed, and one required mechanical ventilation.
The investigation also documented statements from the pharmacy employees involved in preparing the syringes.
Technician #1 told investigators last week that she “could not say for sure if the vial was Mepivacaine or Potassium Phosphate” and that “she wished she had looked more closely at the vials.”
Technician #2 told investigators she had been working under the supervision of Pharmacy Technician #3 because she was nearing the end of her probationary period and had never previously mixed Mepivacaine 2%.
Technician #3, who had supervised the preparation, remained at work at the hospital for the rest of the day after the surgical patients suffered cardiac arrests.
The report states that Pharmacy Technician #1 was placed on leave Aug. 14 pending the investigation and said no one from the facility had contacted him.
When investigators questioned that technician about the medication error, the technician said he “did not know if he needed to talk to the survey team without an attorney…”
Beyond documenting how the pharmacy mistake occurred, the state report describes the severe pain and suffering experienced by the patients after the potassium phosphate was administered.
Ascension Saint Thomas Midtown apologized publicly for the harm caused.
“Our hearts remain entirely with the four patients and families impacted by the recent event at Ascension Saint Thomas Hospital Midtown,” the hospital said. “On behalf of our leadership and care teams, we extend our deepest apologies for the harm caused.”
The investigation indicates that the error was not caught at several opportunities before the syringes reached patients.
The wrong vial was first selected from storage, then carried into the mixing room, where five syringes were filled. Those syringes were labeled with the name of the intended anesthetic before reaching a pharmacist, who approved them without physically matching the medication against the electronic record.
The entire verification took less than half a minute, according to investigators.
The result was that five syringes containing potassium phosphate were presented as Mepivacaine 2% and sent into the hospital’s surgical workflow.
The injuries have now drawn scrutiny from both state health regulators and criminal investigators.
No lawsuits have yet been filed against Ascension Saint Thomas Hospital Midtown.
Families of the affected patients, however, are consulting attorneys as they consider their next steps.
The Tennessee Health Facilities Commission’s full 80-page investigative report provides a detailed account of the pharmacy process, the personnel involved and the failures that allowed the mislabeled medication to reach patients.
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