Twelve days after a medication error at an Ascension hospital in Nashville, Tenn., harmed four patients, one of them is paralyzed below the sternum and being treated in Chicago, The New York Times reported Aug. 26.
The hospital, Ascension St. Thomas Hospital Midtown, has said four joint replacement patients were mistakenly given potassium phosphate instead of mepivacaine, the anesthetic they were supposed to receive, on Aug. 14.
In its most recent statement, St. Louis-based Ascension said Aug. 21, “On behalf of our leadership and care teams, we extend our deepest apologies for the harm caused. Our clinical teams continue to provide dedicated care to these four individuals, and we are offering our full support and spiritual care resources to their loved ones.”
At least one of those patients has transferred to another care facility.
On Aug. 25, Glenda Dorton, a 72-year-old retired schoolteacher from central Tennessee, began receiving care at a spinal injury rehabilitation clinic in Chicago, according to the Times. Ms. Dorton will receive treatment for about six weeks to maximize her physical function as she is paralyzed from the sternum down, the report said.
“I want to be very clear that this was not the doctor’s fault,” Glenda Dorton’s daughter-in-law, Kristina Dorton, told The Tennessean last week. “This was not the anesthesiologist’s fault. This was not the care team’s fault.” She said she had “no reason to believe it could have been an intentional act by a rogue employee.”
Kristina Dorton told the news outlet the surgical teams caught the reactions and halted the remaining joint replacements scheduled that day, and that hospital staff told the family the drugs had come from the pharmacy.
Ascension said it self-reported the error to state regulators on Aug. 14, the day it was identified. The Tennessee Health Facilities Commission has staff on site and is coordinating with CMS, and it notified the Tennessee Bureau of Investigation, which opened an inquiry the same day.
In an Aug. 21 update, the system said it has separated high-alert medications such as mepivacaine into distinctly marked storage, required a second pharmacist to perform final visual and physical checks in spinal medicine workflows, and built in a mandatory stop for independent verification whenever a spinal medication scan triggers an alert. It said it engaged independent, third-party quality experts to validate the changes.
Shubhada Jagasia, MD, president and CEO of Ascension St. Thomas, said leaders have met directly with each of the four families.
The bureau’s involvement raises the prospect of criminal exposure — the path that led to the 2022 conviction of RaDonda Vaught, a Vanderbilt University Medical Center nurse in the same city who was found guilty of criminally negligent homicide after giving a patient the wrong medication in a fatal error in 2017. Medical groups decried her sentencing, saying it would discourage clinicians from reporting safety risks for fear of prosecution.
The nation’s two largest pharmacist groups have pushed back on that possibility. In an Aug. 21 joint statement, the American Society of Health-System Pharmacists and the American Pharmacists Association said they were “deeply saddened” by the harm to Glenda Dorton and “stand firmly against punitive actions that criminalize medication errors.”
No pharmacist, physician, nurse or technician “comes to work intending to harm a patient,” the groups said, adding that those harmed are best honored by strengthening “the systems designed to prevent” such errors.
A key difference from the VUMC case is Ascension has traced this error to the hospital’s pharmacy, and the family has defended the clinicians. Plaintiffs’ firms have begun advertising investigations into the case, but Kristina Dorton said the family is not looking to assign individual blame.
“We’re not looking to ruin somebody’s life,” she said. “They need to figure it out so it never happens.”
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