Overview
- The medication mix-up, which occurred on Aug. 14, involved syringes prepared the day before that delivered potassium phosphate into patients' spines instead of the intended anesthetic mepivacaine.
- All four affected joint‑replacement patients were transferred to higher‑level care, one briefly went into cardiac arrest, one remained on ECMO, and three suffered major lower‑extremity neurologic injury including paralysis.
- Surveyors traced the error to pharmacy failures including look‑alike vials, mislabeled syringes, software that allowed barcode overrides, a probationary technician with documented competency concerns, and a pharmacist final check that took about 29 seconds and did not catch the mistake.
- The Tennessee Health Facilities Commission cited the hospital for immediate jeopardy on three CMS participation conditions, judged the hospital's removal plans unacceptable, and coordinated with the Tennessee Bureau of Investigation, which has an open inquiry but has filed no criminal charges.
- Ascension has imposed safeguards such as separate storage for high‑alert drugs, mandatory independent verification and dual‑pharmacist checks for spinal medications, and national pharmacy groups have urged a just‑culture focus on system fixes rather than punitive prosecutions.