There are things that should NEVER occur in healthcare, and that includes patient death or serious disability from a medication error. They are called never events because they are preventable, and their occurrence reveals a severe problem with hospital management. On Aug 14., a never event occurred at Ascension St. Thomas Hospital Midtown in Nashville, Tenn., and it happened four times. This is completely unacceptable, and we must closely examine what went wrong and ensure it never happens again.
Four patients went to Ascension St. Thomas Hospital Midtown for knee replacement surgery. They walked into the hospital never realizing they may never walk again. This is elective surgery, routine surgery where many patients go home the day of surgery. The patients were probably looking forward to relief from chronic and debilitating knee pain and planning for their post-op rehab. They were greeted in the operating room by the anesthesiologists who explained they would have a spinal anesthetic along with sedation today. The spinal needle was inserted, and the medication was injected into the spinal canal, and that is when the trouble started. The patients all experienced excruciating burning pain and a sense that something was wrong. The label on the syringe stated that the medication injected was 2% Mepivacaine, a commonly used local anesthetic for knee replacements. However, the medication was potassium phosphate, which is a very concentrated electrolyte and, if given in a spinal anesthetic, causes damage to the spine, often paralysis, as well as heart and lung failure.
This medication error had devastating effects and put them in the ICU, required transfer to a second hospital, and as of 9/4/26, three patients have ongoing paralysis and loss of sensation from the midabdominal region, and one patient is still on a ventilator.
On Aug. 15, the Tennessee Health Facilities Commission conducted an unannounced on-site survey after Ascension St. Thomas self-reported the medication error. The commission works with the Centers for Medicare and Medicaid Services to ensure hospital safety in the state. The survey revealed that three Immediate Jeopardies had been identified, and these are:
Pharmaceutical Services
Surgical Services
Governing Body of the hospital
Immediate Jeopardies are the most serious deficiency notices regulators issue; they involve a serious risk of injury, harm, or death to patients and must be remedied ASAP.
This article is the first in a series that will cover the horrific errors in pharmaceutical services at the hospital, and subsequent articles will examine issues with surgical services and hospital governance.
Anesthesia has two options for obtaining the medication they inject. The first option is for anesthesiologists to obtain a single-use vial of Mepivacaine containing 20 mL, visually confirm it is the correct medication and dose, and verify that it has not expired. At this point, they would draw up 3 mL of medication, inject it into the patient, and discard the vial. The advantage is that anesthesiologists can verify they are giving the patient the correct medication. They can also confirm the medication with the circulating nurse as a safety check. The vial costs about $10 and wasting most of it isn’t an issue. This is a very simple method that allows the person who delivers the drug to you to verify it is the correct drug. This is the method that is used at ambulatory surgery centers or freestanding surgery centers.
As an obstetrician for 40 years, I have witnessed and participated in this method, and I have never seen a medication error or complication. The other option is for the hospital pharmacy to prepare the medication ahead of time for all patients, label it, and send it to the operating room, as is done at St. Thomas. The advantage is that you prepare the medication in a sterile room, which reduces infection risk. This is a bigger issue when you are combining multiple drugs and/or diluting the drugs to change the strength. In this scenario, the drugs are drawn up directly from a sterile vial, so the risk of infection is minimal.
The second advantage is that you can prepare multiple syringes from a single vial of medication and reduce the amount of drug wasted. This is an issue if the medication is expensive or in short supply, and neither is the case for Mepivacaine.
The disadvantage of preparing syringes in the pharmacy is that it complicates a very simple procedure and involves multiple people, increasing the risk of error. In this case, there were five people involved in preparing and administering the drug to the four patients over almost a 24-hour time period. The team included three pharmacy technicians, a pharmacist, and the anesthesiologist.
The criteria for certification for the team members include:
Pharmacy Technicians:
- High school diploma or a GED
- Either in-person or online training
- OR work experience (500 hours)
- Certifying exam
- High school diploma or a GED
Pharmacists
- Completion of a PharmD program (6-8 years post high school)
- Passing national and state board exams
- Residency training depending on the specific job
- Hospital experience
Anesthesiologists
- College degree: 4 years
- Medical School: 4 years
- Residency: 4 Years
- Possible fellowship: 1 year
The hospital uses video surveillance, image capture, barcode scanning, and pharmacy software to reduce the risk of errors. Pictures and video surveillance allow staff to review and verify that the medication is prepared correctly, and they also allow the State inspectors to see the chain of events involving the medication error.
On Ag.13 at 10:14 a.m., pharmacy technician #1 reviewed an order for 6 syringes of 4ml of 2% Mepivacaine. She then selected a 20 mL vial of the correct medication, Mepivacaine 2%, from a storage bin and brought it to a work surface. The technician then scanned and photographed the medication in the pharmacy software.
Scanning the barcode reveals the National Drug Code (NDC), a unique identifier that identifies the drug, concentration, and total dose. This also shows the medication’s lot number and expiration date. The barcode scan should match the drug order, which serves as a safety check.
The 20ml vial can be used to make five syringes with 4ml of medication, and therefore a second vial of medication was required. This time, the technician went to a different storage bin and returned with a vial of potassium phosphate. When this vial wouldn’t scan, the technician replaced the correct vial in the potassium phosphate bin, took another vial of potassium phosphate, and took more photographs of the incorrect medication. The pharmacy technician was able to override the pharmacy software and manually input the erroneous drug information into the system. At 10:37 am, the technician placed the two vials of potassium phosphate, five unopened syringes, and six labels stating the medication was 2% mepivacaine (which is untrue) into a transport bin for the next part of the medication preparation process.
The critical errors that were made by pharmacy technician # 1 include:
Not examining the vial of potassium phosphate, which would have clearly shown it was the wrong medication.
Overriding and manually entering data into the system when the barcode failed to scan. This should have been a hard stop, with the medication brought to the pharmacist for review.
Returning the correct vial of 2% Mepivacaine and placing that in a storage bin with potassium phosphate. It is strange that she chose to place the vial that scanned back into the bin and chose another vial that didn’t
Taking the time to take pictures of the incorrect vials and NOT looking at the vials to verify they were correct. The staff focused more on getting past the software than on its intent of verifying the medication.
Pharmacy technician #2 and #3 were involved in the next phase of the medication preparation. This was because Pharmacy Technician #2 received a coaching feedback form that morning, and Pharmacy Technician #3 was present to provide oversight training and sign her off on the probationary period. There was no documentation that Pharmacy Technician #3 was able to evaluate, train, or serve as a preceptor.
The areas of concern with Pharmacy Technician #2 included:
- Difficulty understanding common intravenous medication terminology
- Problems with using the pharmacy software to produce labels and enter the medications into the software
- Applying medication-related calculations
- Performing routine parts of the job without coaching and supervision
At 10:50 am, Pharmacy Technician #2 obtained the bin containing the medication, syringes, and labels, withdrew 4cc of potassium phosphate into each of the five syringes, and took photographs of the syringes and the vials. Pharmacy Technician #2 then placed the syringes and labels into a container and sent it to the pharmacist on duty for approval. The vials were discarded after the medication was drawn up. This meant that the pharmacists couldn’t visually inspect the vials to confirm the correct drug was used. Pharmacy Technician #3 was seen looking at the items removed from the transport bin, then sat down and observed Pharmacy Technician #3’s actions.
In a subsequent interview, Pharmacy Technician #2 reported that Pharmacy Manager #1 asked her to work the day shift on Aug. 13 to get signed off of her probationary period. Pharmacy Technician #3 was providing her with oversight training on Aug. 13. Pharmacy Technician #2 reports that she had never drawn up Mepivacaine and always has her trainer check behind her in these situations. She reports that Pharmacy Technician #3 checked it with me and approved it. The Health Facilities Commission Surveyor asked if she looked at the vial, and she stated that it had been normal practice for vials to NOT be checked in the mixing room. When asked whether she reviews pictures to verify the vials before drawing up the medication, she reported that she doesn’t typically look at them. You just find the name, click on it, and take pictures. This shows that staff were conditioned to work through the pharmacy software quickly and not focus on the importance of verifying medication orders.
The critical errors made by Pharmacy Technicians #2 and #3 include:
Failing to independently verify that the vials in the bin were the correct medication. All that was required was to examine the vials and read the label: potassium phosphate!
Taking pictures of the vials and NOT looking at the vials, which clearly state: potassium phosphate.
Pharmacy Technician #3 looked at the contents of the bin, but failed to look at the vial, read it, and compare it to the order. This occurred despite being in a training and supervisory capacity.
Drawing up the medication into the five syringes and not verifying the medication in the vial. You would say, I now draw up 4ml of Mepivacaine and notice that the vial is potassium phosphate!
Not realizing there were 5 syringes and the order called for six. This is a sign that something has gone wrong with the order, and I should start over.
Discarding the vials prior to sending the medication-filled syringes to the pharmacist for approval. This removes an easy way for the pharmacists to verify the correct medication was chosen.
Video revealed that Pharmacist #1 was at a computer at 11:06 and did not bring the bin containing the five filled syringes to the computer to compare them to the medication information displayed during verification. The verification process included reviewing the medication order in the pharmacy software, along with photographs of the product selection through completion. The pharmacist took about 29 seconds to review the medication and electronically verified and approved it. Additional labels were printed with the medication name, lot number, expiration date, and the names of everyone involved in the process. The pharmacist then attached the new labels to the five syringes, and they were sent out for administration the next day. The law clearly states that no medication should be released to a patient without a pharmacist verifying the functions completed by pharmacy technicians. Therefore, the pharmacist is responsible for all actions of the pharmacy technicians under his or her supervision.
The critical errors made by the pharmacists include:
Not comparing the five filled syringes at the workstation to the order. The order called for six syringes, and only five were prepared. This is a red flag that the order was incorrectly filled.
Not examining the 6 pictures taken by the pharmacy technicians. Pictures 1 and 2 reveal a 20 mL vial of Mepivacaine and 5 Mepivacaine labels. Pictures 3 and 4 show two 15 mL vials of potassium phosphate, syringe supplies, and six Mepivacaine labels. These two pictures reveal the error; the medication should have been discarded, and the process completed by the pharmacists, not the technicians.
Picture 5 revealed five syringes with 4ml of clear liquid and two 15ml vials of potassium phosphate visible in the background. The last picture reveals the five syringes with the erroneous 2% Mepivacaine labels. These two pictures also show that pharmacists would need to discard the medication and complete the process without technicians.
The pharmacists should have insisted that the medication vials were included with the syringes. This is a very easy way to verify the correct medication was used.
The next day, the syringes were delivered to the anesthesiologist to administer to the patients. This process now involved five different people over a 20-hour period. The most highly trained person administering the drug had no way to verify that it was the correct medication. Both Mepivacaine and potassium phosphate are clear fluids and can’t be distinguished by visual exam. Four patients received the wrong medication; their story will be told in the next installment of : The Cost of Medical Errors.
