A medication mix-up that paralyzed a 72-year-old Nashville, Tenn., patient has pulled national pharmacy and anesthesiology groups into renewed scrutiny of whether clinicians should be criminally charged for errors.
On Aug. 14, four joint replacement patients at Ascension St. Thomas Hospital Midtown in Nashville, Tenn., received potassium phosphate instead of the intended anesthetic mepivacaine, the hospital said. It traced the incident to its pharmacy.
One of the patients, Glenda Dorton, was left paralyzed from the sternum down and was transferred Aug. 25 to a Chicago spinal-injury rehabilitation facility for roughly six weeks of care. The hospital said all four experienced adverse reactions and received immediate care but has not detailed the conditions of the other three.
Ms. Dorton’s family has publicly defended the clinicians who treated her.
“This was not the doctor’s fault. This was not the anesthesiologist’s fault. This was not the care team’s fault,” her daughter-in-law, Kristina Dorton, said.
Ascension reported the error to state regulators the day it occurred, and the Tennessee Bureau of Investigation opened an inquiry the same day. No charges have been filed. But the investigation revived a question the city confronted a few years ago — one that turns a medication error into a possible crime.
Two of the nation’s largest pharmacy organizations moved quickly to draw a line. In an Aug. 21 joint statement, the American Society of Health-System Pharmacists and the American Pharmacists Association said they “stand firmly against punitive actions that criminalize medication errors,” calling instead for a just-culture approach built on transparency and reporting. “No pharmacist, physician, nurse, technician, or other healthcare professional comes to work intending to harm a patient,” the organizations said.
The same day, the American Society of Anesthesiologists, the Anesthesia Patient Safety Foundation and the Society for Obstetric Anesthesia and Perinatology reaffirmed that spinal anesthesia “remains a safe and essential anesthetic technique when administered with appropriate medication.” A drug error delivered into the spine is distinct from a complication of the technique itself, they said.
Matthew Byrnes, MD, a surgeon at Catalina Island (Calif.) Health, told NBC affiliate WSMV that most medications look identical in the syringe, making labeling before surgery a critical safeguard.
“You wouldn’t know the difference between 95% of medications. They all look like water,” Dr. Byrnes told WSMV. “The last person standing has the ultimate responsibility.”
In 2022, former Vanderbilt University Medical Center nurse RaDonda Vaught was convicted and sentenced to three years of supervised probation for a fatal medication error. Nursing and hospital groups called her prosecution “a backward step for patient safety.” They warned it would push clinicians to hesitate before reporting mistakes.
That fear has begun to reshape law. In April 2024, Kentucky became the first state to decriminalize medical errors when Gov. Andy Beshear signed House Bill 159, shielding providers from criminal liability for harm tied to care, with exceptions for negligence and intentional harm.
Patient-safety experts have long argued the two goals collide.
“We cannot punish our way to safer medical practices,” Nancy Foster told Becker’s in 2022; she was serving as the American Hospital Association’s vice president for quality and patient safety policy at the time.
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