Part One looked at how the hospital pharmacy prepared the spinal medications. Part Two examines what the surgical team did—or failed to do—after the wrong drug was injected.
A second unannounced inspection by state and federal regulators (September 4–6, 2026) found that Ascension Saint Thomas Midtown in Nashville, Tennessee, did not respond quickly or effectively to the medication error. Doctors delayed assessing the patients, coordinating care, and starting the main treatment (CSF lavage). Those delays worsened the patients’ condition.
What Went Wrong and Why It Matters
A spinal anesthetic is a shot of medication into the fluid that surrounds the spinal cord (cerebrospinal fluid, or CSF). It is meant to numb the lower body for surgery. The anesthesiologist at this hospital had no way to verify the syringe’s contents. The pharmacy prepared and labeled the syringes. The anesthesiologist had to trust that the contents matched the label.
The syringes contained potassium phosphate, a concentrated electrolyte solution meant only for careful dilution for intravenous use. Injecting it into the spinal fluid can cause:
- Severe damage to the spinal cord and nerves
- Paralysis of the legs (or arms and legs)
- Dangerous heart rhythms or complete heart stoppage
- Breathing failure
- Death
The main treatment shown in case reports is CSF lavage: removing the contaminated fluid through a small catheter placed in the lower back and replacing it with sterile saline. The sooner this is done, the better. Best results are seen when it starts within 1–2 hours; it can still help up to about 5 hours. Delays reduce the chance of recovery.
Patient #1
August 14, 2026
- 6:52 a.m. – Spinal started. Patient immediately reported severe burning pain in the tailbone area and a feeling of needing to go to the bathroom. Injection stopped after 1.5 mL (half the planned dose). Surgery canceled.
- 8:30 a.m. – Arm itching and weakness (symptoms spreading upward—abnormal for a normal spinal).
- 9:45 a.m. – No sensation from the abdomen down (spinal should have been wearing off by this point).
- 11:00 a.m. – Breathing tube placed; transferred to ICU.
- Afternoon – Heart and lung function deteriorated. Doctors chose ECMO (a heart-lung machine) over placing a lumbar drain for lavage. Patient transferred to another hospital.
Patient later needed a tracheostomy (neck breathing tube) and has significant ongoing neurologic problems. Early verification with the pharmacy that morning could have stopped the other three patients from receiving the same drug and allowed earlier lavage for Patient #1.
Patient #2
Spinal completed at 7:58 a.m. (full 3 mL dose). Knee surgery was finished.
- Recovery room: arm pain that increased to 10/10.
- Moved to ICU.
- Burning leg pain after the spinal had been noted earlier; the patient was sedated, and surgery continued.
- Lumbar drain placed around 4:35 p.m. (more than 8 hours after the spinal).
- Transferred to the second hospital. Lavage performed there.
Discharged to rehab; remains paraplegic (paralyzed in the lower body).
Patient #3
Spinal at 8:10 a.m. Patient had right-leg pain that did not resolve when the needle was removed. Only a small amount (0.25 mL) was given; surgery was completed under general anesthesia.
- Recovery: itching and chest/arm pain (symptoms rising).
- Moved to ICU.
- A lumbar drain was placed in the late afternoon. CSF potassium levels checked and lavage performed.
Later notes show she can move her legs but not normally. Discharged to rehab with residual limitations. Hospital leadership said she was “back to normal,” but neurology documented ongoing deficits.
Patient #4
Spinal at 9:30 a.m. (1.9 mL). Patient went limp, and his heart stopped briefly, then recovered. Severe back pain. Surgery canceled.
- Numbness and itching spread upward. With a normal spinal, the numbness should be going lower.
- Later: high heart rate, high blood pressure, rapid breathing, muscle spasms.
- Breathing tube placed. Transferred to the second hospital.
- CSF potassium later measured at 6.4 (normal roughly 2.8–3.0)—very high. Lavage appears to have started after 10 p.m., more than 12 hours after the injection.
Remains paraplegic.
What the Regulators Found
Regulators concluded that the hospital failed to ensure that the physicians responsible for spinal anesthetics knew how to manage an accidental wrong-drug injection. There was no treatment protocol, so doctors had to research options while the patients deteriorated. This delayed CSF lavage for all four patients and increased the risk of permanent harm.
Key timeline points from the second inspection:
- ~10 a.m. – Leadership notified.
- Literature search and poison control contacted.
- Around noon – Decision that lumbar drains and lavage were needed.
- 4 PM The lumbar catheters were placed. (A delay of 4 hours).
- 5:30 PM Protocol decided on. (A delay of 5 ½ hours)
- 7:00 PM Neurosurgeon who performs the lavage arrives. (A delay of 7 hours).
- There is NO documentation of when the lavage started or ended for any of the patients. A delay of? hours.
Missed Opportunities
- No immediate check with pharmacy of the compounding photos/videos.
- The anesthesiologists didn’t suspect wrong drug administration. There was unusual pain and burning, and the anesthesiologist had no way of directly verifying the medication.
- No sequestering of remaining syringes.
- The same anesthesiologist managed all four cases and did not recognize the pattern until later.
- Elective cases continued.
- Not implementing CSF lavage until 12+ hours had elapsed for patients. This is typically outside the time range in which the procedure is effective at preventing permanent harm.
The hospital has since changed its process: anesthesia now draws the medication directly from the manufacturer’s vial instead of using pharmacy-prepared syringes.
A full review of the event is still needed to understand exactly what happened and prevent anything similar in the future. The goal of that review should be improving safety, not simply assigning blame.
Part Three will examine the role of the hospital’s governing body.
