Four patients enter the hospital for scheduled orthopedic surgery and receive potassium phosphate in place of the anesthetic intended for the procedure. The mistake caused serious paralysis in two of them. It happens at Ascension Saint Thomas Hospital Midtown in Nashville, Tennessee, United States. The hospital admitted that the error occurred within its pharmacy and introduced new safety procedures.
The swap: potassium phosphate instead of mepivacaine
The four patients were supposed to receive mepivacaine, a local anesthetic, but potassium phosphate was found in the syringes prepared by the pharmacy. “The four patients experienced adverse reactions and received immediate medical attention,” the facility said. An internal review also found that no other patients were involved in the error, according to Ascension.
Potassium phosphate is a drug actually used in medicine, but with specific administration methods. The Food and Drug Administration explains that the product is intended for intravenous infusion and warns that improper administration, too rapid or not adequately diluted, can cause very serious consequences, including arrhythmias and cardiac arrest.
Glenda Dorton paralyzed after knee surgery
Among the patients involved is Glenda Dorton, 72, who arrived at the hospital for knee surgery. The family says that the orthopedic surgery was successful, but when she woke up the woman could no longer feel or move her body from the chest down.
His lawyer Mark Walwyn explained to the CBS that the prognosis remains uncertain and that the woman faces “a long and uncertain recovery”. The family is now trying to understand whether at least part of the damage could be reversible.
“I want to be very clear: it wasn’t the doctor’s fault and it wasn’t the anesthesiologist’s fault,” Kristina Dorton, the 72-year-old’s daughter-in-law, told the Tennessean, reporting that the family had been informed that the drug came directly from the hospital pharmacy.
Hospital changes procedures after mistake
The hospital’s president and CEO, Shubhada Jagasia, apologized to the families: “On behalf of our management and care teams, I am deeply sorry for the harm caused to our patients.” The facility claims to have identified the error, reported it to state authorities the same day and immediately opened its own investigation.
Three main measures have been introduced since the review: medicines considered high risk are stored in separate and clearly marked areas, an alarm in the scan of a medicine intended for spinal administration now triggers a mandatory stop until independent verification and, finally, the preparation of spinal medicines must be checked by a second qualified pharmacist before use. Ascension also engaged external experts to evaluate corrective measures.