Ascension Saint Thomas said four joint replacement patients were harmed after a pharmacy error at its Midtown hospital on Friday, Aug. 14, when they received potassium phosphate instead of mepivacaine. The hospital said the patients had adverse reactions and got immediate medical care.
The disclosure matters now because the hospital has now named the drugs involved in a mix-up it previously described only as a harmful medication error. It also said leadership self-reported the incident to state regulators the same day it identified it, turning a private patient-safety failure into a matter for state and federal review.
The hospital said a comprehensive review found no other patients were affected. It also said it has put in place physical, technological and clinical safeguards and brought in independent quality experts to review and validate its mitigation plans. The language points to an effort to show the mistake was contained, but it also leaves unanswered how a pharmacy could send out potassium phosphate in place of mepivacaine in the first place.
One of the patients was Glenda Dorton, her family said. They said the 72-year-old went to Saint Thomas Midtown on Aug. 14 for a routine knee replacement and was supposed to receive an anesthetic through an epidural before surgery, but was instead given potassium from the hospital pharmacy. Her family said she woke up unable to feel or move from the sternum down and was later told she has T-6 paralysis.
That account sits alongside the hospital’s description of four patients who experienced adverse reactions and received immediate care. The difference is more than wording. It is the gap between a disclosed medication error that was treated and a family saying one of the patients came out of surgery with a life-altering injury.
Ascension Saint Thomas said it continues to work with state and federal officials after the self-report and remains committed to the patients and families affected. What readers still do not have is a clear explanation of the pharmacy failure itself, or whether the safeguards now in place would have stopped this one before it reached the patient.
