Ascension Saint Thomas Hospital Midtown in Nashville, Tenn., has confirmed an “isolated medication error” that occurred in its pharmacy Aug. 14 affected four patients who are continuing to receive care.
Six things to know:
1. Four joint replacement patients were mistakenly given potassium phosphate instead of mepivacaine, the anesthetic they were supposed to receive, according to an Aug. 21 hospital news release.
2. The patients had adverse health reactions and were treated immediately, the hospital said, adding that a follow-up review found no other patients were affected.
3. Hospital leadership reported the error to state regulators Aug. 14, the release said. The Tennessee Bureau of Investigation told Becker’s on Aug. 20 that it was investigating the safety event. The Tennessee Healthcare Facilities Commission informed the TBI of the situation the evening of Aug. 14, when the TBI opened its investigation. THFC staff are on site investigating complaints and are coordinating with CMS to ensure patient safety, commission Executive Director Logan Grant confirmed to Becker’s on Aug. 20.
4. Ascension Saint Thomas is also working with outside quality experts to review and sign off on its corrective steps, in addition to its ongoing coordination with state and federal officials.
5. The hospital said it has made changes to pharmacy procedures and safety protocols aimed at preventing the error. They include keeping high-alert drugs such as mepivacaine in separate, clearly marked spots to prevent mix-ups; adding a mandatory stop-and-verify step for any spinal medication scan alert; and requiring a second trained pharmacist to perform a final visual and physical check on spinal medicine orders.
“Providing safe, high-quality, patient-centered care is at the core of our mission,” the release said. “Any gap in meeting that standard receives our immediate, uncompromising attention. We remain steadfastly committed to supporting those affected and upholding safety standards for every person who trusts us with their care.”
6. A woman told WKRN her mother-in-law became paralyzed after receiving potassium during a knee replacement surgery at the hospital, the CBS affiliate reported Aug. 18. According to the patient’s daughter-in-law, Kristina Dorton, the 72-year-old woman underwent the knee replacement Aug. 14; the procedure itself was successful, but Ms. Dorton said the surgical team is believed to have administered potassium instead of the intended local anesthetic, bupivacaine, during spinal anesthesia. The patient was moved to the ICU afterward and, as of Aug. 18, had no feeling, movement or pain response from her breastbone down, according to WKRN.
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