Nashville hospital admits pharmacy error in incident leaving at least one paralyzed

NASHVILLE, Tenn. (WZTV) — Ascension Saint Thomas is revealing new details about a medication error at its Midtown hospital that harmed four joint replacement patients, saying the patients mistakenly received potassium phosphate instead of an anesthetic medication.

The hospital said the error happened Friday, Aug. 14, inside the pharmacy at Ascension Saint Thomas Hospital Midtown.

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According to a statement released Friday, the four patients were supposed to receive mepivacaine, an anesthetic medication. Instead, the hospital said they received potassium phosphate.

“The four patients experienced adverse health reactions and received immediate medical care,” the hospital said.

Ascension Saint Thomas said a comprehensive review confirmed no other patients were affected.

The new information comes after FOX 17 News spoke with the family of 72-year-old Glenda Dorton, who said she went to Saint Thomas Midtown on Aug. 14 for a routine knee replacement and was one of the patients impacted.

Dorton’s family previously told FOX 17 News she was supposed to receive an anesthetic through an epidural before surgery but was instead given potassium. Her family said she woke up after surgery unable to feel or move from the sternum down and was later told she has T-6 paralysis.

The family said they were told the medication came directly from the hospital pharmacy.

Ascension Saint Thomas is now confirming the medication error occurred in its pharmacy, adding hospital leadership self-reported the incident to state regulators after identifying it Aug. 14.

“Our hearts remain entirely with the four patients and families impacted by the recent event at Ascension Saint Thomas Hospital Midtown,” the hospital said. “On behalf of our leadership and care teams, we extend our deepest apologies for the harm caused.”

Ascension Saint Thomas is revealing new details about a medication error at its Midtown hospital that harmed four joint replacement patients, saying the patients mistakenly received potassium phosphate instead of an anesthetic medication. (Photo: FOX 17 News)

Hospital implements new safeguards

Ascension Saint Thomas said it has since implemented several physical, technological and clinical safeguards aimed at preventing a similar medication error.

The hospital outlined the following changes:

• Isolated medication storage: High-alert medications are now stored in separate, distinctly marked locations to reduce the risk of selection errors.
• Mandatory hard-stop and escalation: Any spinal medication scan alert must now trigger a stop and be resolved through independent verification.
• Independent dual verification: Spinal medication workflows now require a second trained pharmacist to perform final visual and physical checks.

The hospital also said it continues to collaborate with state and federal officials following its self-report and has engaged independent, third-party quality experts to review and validate its mitigation plans.

“Any gap in meeting that standard receives our immediate, uncompromising attention,” Ascension Saint Thomas said. “We remain steadfastly committed to supporting those affected and upholding safety standards for every person who trusts us with their care.”

The latest statement provides the first public explanation from the hospital of exactly what went wrong after Ascension Saint Thomas initially acknowledged that four patients had been harmed but did not disclose the specific medication error.

Ascension Saint Thomas says its comprehensive review found no other patients were affected.