Ascension has confirmed that a pharmacy error at its Saint Thomas Midtown hospital in Nashville caused four joint replacement patients to receive potassium phosphate instead of their intended spinal anesthetic.
This mix-up, which occurred on August 14, left one patient paralyzed and caused adverse reactions, the health system said in a statement published on Friday.
“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,” the statement read.
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After identifying the error, Ascension reported the incident to state regulators and has since implemented safeguards to prevent this scenario from happening again, including isolated storage for high-alert medications and mandatory independent dual verification for spinal medication workflows.
The health system also said it has brought in outside quality experts to review and validate its corrective action plan.
The Tennessee Bureau of Investigation opened a criminal investigation into the incident after receiving a referral from the Tennessee Health Facilities Commission last week. No charges have been filed, and the agency has not said whether any individual staff members are under scrutiny.
The probe has drawn comparisons to another notorious patient safety event from Nashville — the 2019 case of former Vanderbilt nurse RaDonda Vaught, who was criminally prosecuted after a fatal medication error.
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That case remains a flashpoint among nurses, with many torn over whether honest mistakes should carry criminal liability.
As TBI’s investigation unfolds, the case will likely reignite debate about how medication errors at overburdened hospitals should be handled. And as AI becomes more and more integrated into clinical workflows, the question of how to assign blame for medication blunders is becoming even more complex.
For now, Ascension said its focus remains on the four patients and their families.
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