A Hospital Names the Drug Involved
Ascension Saint Thomas has confirmed that four joint replacement patients at its Midtown campus in Nashville were given potassium phosphate instead of the anesthetic they were supposed to receive, in an error the health system says originated inside the hospital pharmacy.
In a statement posted by Ascension, the system said the error occurred on Friday, August 14, that the patients were meant to receive mepivacaine, a local anesthetic, and that all four experienced adverse health reactions and received immediate medical care. A comprehensive review confirmed no other patients were affected, the statement said. Hospital leadership self-reported the event to state regulators the day it was identified.
The confirmation matters because for a week the specifics were unclear. Family accounts and early local reporting described a potassium injection given in place of bupivacaine, a different anesthetic. Readers following this story should treat the hospital statement, rather than the earlier family descriptions, as the current account of the drugs involved.
The most widely reported patient is Glenda Dorton, 72, who underwent a knee replacement at the hospital. Her attorney, Mark Walwyn, told CBS News that the operation itself went well but that she is currently paralyzed, and he described her prognosis as unclear but dire. In a statement on behalf of the family, Walwyn said she remains under medical care and is "facing a long and uncertain recovery." Her relatives told local outlets she has no feeling or movement from roughly the breastbone down.
CBS News also reported, citing its local affiliate, that families said two patients were left paralyzed and one was in intensive care. All four operations were supposed to be outpatient procedures. The hospital has not released details about the condition of the other patients, citing patient privacy, and has said it would not share specific clinical details.
That distinction should stay visible. The paralysis accounts come from families and their attorneys and from local reporting, not from the hospital or from any regulator. What the hospital has confirmed is the drug substitution, the number of patients, that all four had adverse reactions, and that all four received immediate care.
Shubhada Jagasia, president and chief executive of the hospital, said in an earlier statement: "I am deeply sorry for the harm caused to our patients." She said leadership had met directly with each family, connected them with spiritual care teams and ensured access to ongoing care and other appropriate resources.
Two Investigations Are Running in Parallel
The Tennessee Bureau of Investigation told Becker's Hospital Review it is actively investigating after the Tennessee Health Facilities Commission alerted the agency to the incident. Commission investigators were on site at the hospital the week the error came to light. A criminal investigative agency examining a hospital medication error is unusual and moves the matter beyond an internal quality review. No one has been charged, and no wrongdoing has been established.
Separately, the hospital said it has brought in independent quality experts to review and validate its corrective plans, and has already changed how it handles the medications involved. Those changes, detailed by NewsChannel 5 Investigates, include storing high-alert medications such as mepivacaine in separate, distinctly marked locations; requiring a hard stop and independent verification whenever a spinal medication scan generates an alert; and requiring a second trained pharmacist to perform final visual and physical checks on spinal medication workflows.
Potassium phosphate is a legitimate hospital medication. It is given intravenously, after appropriate dilution, to correct low phosphate levels and in nutrition support. It is not intended for injection into the space around the spinal cord, and it appears on the Institute for Safe Medication Practices list of high alert medications, a designation reserved for drugs that carry heightened risk of serious harm when used incorrectly. Concentrated potassium has carried that designation for decades precisely because the consequences of a substitution error are severe rather than merely inconvenient.
The Question Patients Are Right to Ask
For anyone scheduled for surgery, the useful takeaway is not that hospitals are unsafe. It is that certain categories of medication carry known catastrophic failure modes, and that the safeguards against them are procedural rather than automatic.
Patients and family members can reasonably ask, before a procedure, which medications will be administered and whether the facility uses independent double-checks for high-alert drugs. Asking a nurse or anesthesia clinician to name the medication being administered and confirm it against the chart is a normal patient safety practice, not an accusation. Families who are present can also ask what the plan is if a patient reports an unexpected reaction such as burning, itching, or sudden loss of sensation.
Nobody should cancel necessary surgery because of this incident. Joint replacement remains a common and generally safe procedure. But patients who want to check a facility's record can review state health department inspection findings and accreditation reports, both of which are public in most states.
Anyone who believes they were harmed by a medication error can file a complaint with their state's health facility licensing agency, and should keep dated records of symptoms, medications, and communications with the hospital before speaking with a clinician or attorney.
Answers That Have Not Arrived Yet
Several central questions remain open. Investigators have not publicly explained how potassium phosphate came to be dispensed in place of mepivacaine, or which specific safeguards failed to catch the substitution before it reached four separate patients. No findings have been released, no conclusions have been reached, and no determination has been made about whether anyone will face professional or legal consequences.
The condition and prognosis of the affected patients also remain outside the public record, apart from what families have chosen to describe. Whether any of the neurological damage can be reversed remains an unanswered medical question.
The Tennessee Bureau of Investigation has not given a timeline. The Tennessee Health Facilities Commission has not published findings. MedicalDaily will report on the outcomes of both reviews, any regulatory action against the facility, and any updates the hospital provides about the patients involved.
Key Questions Answered
What did the hospital confirm? Ascension Saint Thomas said four joint replacement patients at its Midtown campus received potassium phosphate instead of the intended anesthetic, mepivacaine, due to an error at the hospital pharmacy.
How many patients were harmed? Four. The hospital said all four had adverse health reactions, and a review found no other patients were affected.
Is it confirmed that patients were paralyzed? Family members, an attorney, and local reporting have described paralysis in at least one and possibly two patients. The hospital has not confirmed individual patient conditions, citing privacy.
Who is investigating? The Tennessee Bureau of Investigation, after the Tennessee Health Facilities Commission notified it. The hospital also self-reported to state regulators and hired outside quality experts.
What has the hospital changed? Separate storage for high-alert medications, a mandatory hard stop and independent verification for spinal medication scan alerts, and a required second pharmacist check on spinal medication workflows.
What is potassium phosphate normally used for? Intravenous correction of low phosphate levels and nutrition support, after appropriate dilution. It is classified as a high alert medication.
What should patients scheduled for surgery do? Continue with medically necessary procedures, and feel free to ask clinicians to name and verify medications being administered. That request is a standard safety practice.
