A medication mix-up at a Nashville hospital left 4 surgical patients with serious injuries, including paralysis, after they were mistakenly given potassium phosphate instead of the anesthetic mepivacaine.
The error occurred at Ascension Saint Thomas Hospital Midtown on August 14, 2026, as patients were undergoing what were expected to be routine joint replacement procedures.
An 80-page investigation report from the Tennessee Health Facilities Commission has since provided a detailed account of how the wrong medication made its way through the hospital pharmacy and into syringes labeled as the intended anesthetic.
If you or a loved one has suffered a catastrophic injury or wrongful death after a medication error in Florida, schedule a free consultation with the Tampa medication injury attorneys at Palmer Lopez to learn about your legal options.
What happened at Ascension Saint Thomas Hospital Midtown?
Glenda Dorton, a 72-year-old retired schoolteacher, was one of 4 patients who suffered serious adverse reactions after receiving potassium phosphate instead of mepivacaine during procedures at Ascension Saint Thomas Hospital Midtown.
According to The New York Times, when Dorton woke after a knee replacement, she could not move or feel anything below her sternum.
Her daughter-in-law told the Times that doctors placed Dorton on a ventilator, drained her spinal fluid to remove excess potassium, and administered high-dose steroids in an attempt to reverse the damage. Dorton has since been transferred to a spinal injury rehabilitation facility in Chicago, where she’s expected to undergo intensive treatment for the next 6 weeks.
The other patients also experienced serious complications. According to the Tennessee Health Facilities Commission report, all 4 affected patients required transfer to a higher level of care. One required extracorporeal membrane oxygenation (ECMO), which provides life support for the heart and lungs, while 3 experienced significant neurological impairment, including paralysis and loss of sensation.
Treating the patients presented an unusual medical challenge. A neurologist at the hospital that received the transferred patients told investigators there was no prescribed protocol for this type of event and no formal research to guide best practices.
Ascension said hospital leaders stopped the remaining surgeries scheduled for August 14 after recognizing adverse reactions among the patients.
How did the medication error at Ascension Saint Thomas happen?
The Tennessee Health Facilities Commission investigation provided a detailed timeline of what happened inside the hospital pharmacy the day before the surgeries.
According to the report, a pharmacy technician initially retrieved a vial of the correct medication, mepivacaine 2%. When she returned for an additional vial about 20 minutes later, however, she went to a different storage bin and retrieved potassium phosphate instead.
When the potassium phosphate did not scan properly, the technician returned the original vial of mepivacaine and retrieved a second vial of potassium phosphate. The 2 potassium phosphate vials were placed in a transfer bin with unopened syringes and labels identifying the medication as mepivacaine.
A second pharmacy technician then used the potassium phosphate to fill 5 syringes and labeled them as mepivacaine.
During the final verification, the pharmacist reviewed the medication order and photographs from the preparation process but did not bring the prepared syringes to the computer workstation to directly compare them with the medication information displayed on the screen.
The error was not detected, and the mislabeled syringes were sent for use during the patients’ procedures the following day.
In all, 3 pharmacy technicians and 1 pharmacist were involved in preparing, verifying, and dispensing the medication without detecting the error.
The report noted that one technician was working an additional shift in a float position, while another was nearing the end of her probationary period and had not previously mixed mepivacaine 2%.
Investigators also found that potassium phosphate remained on the pharmacy wall for days after the incident without a label identifying it as a high-alert medication. The report cited human error as the primary cause of the mix-up.
$2 Million Verdict Awarded in the First Detransitioner Malpractice Lawsuit in the U.S.
A woman was awarded $2 million after a jury found medical providers failed to follow proper standards of care in her gender-affirmation surgery as a minor.
What changes did Ascension make after the medication error?
Ascension Saint Thomas apologized to the affected patients and their families and said it implemented changes to its pharmacy procedures and safety protocols. The pharmacy technician who initially selected the medication and the pharmacist who conducted the final verification were also placed on leave following the incident.
According to Ascension, the hospital’s new procedures include storing high-alert medications in separate, distinctly marked locations and requiring a second trained pharmacist to perform final visual and physical checks of spinal medications.
Ascension also implemented a new process requiring staff to stop and independently verify any spinal medication if the scanning system generates an alert.
In addition to the investigation by the Tennessee Health Facilities Commission, the medication error is also the subject of an investigation by the Tennessee Bureau of Investigation.
Dorton’s family told the Times that it planned to wait until the official investigations were completed before considering legal action.
When is a medication error considered medical malpractice?
Medication errors can happen at several points between the time a medication is ordered and when it reaches a patient.
For example, a doctor may prescribe the wrong medication or dose, a pharmacist may make an error while preparing or dispensing it, or a nurse or anesthesiologist may administer it incorrectly.
When a true medication error occurs, it may indicate that the accepted standard of care was not met somewhere along this chain.
However, an error alone does not necessarily mean there is a medical malpractice claim. Generally, a patient must also show that the error caused an injury or made an existing condition worse.
Were you or a family member injured by a medication error in Tampa? We can help.
Determining who may be responsible for a medication mix-up often requires looking beyond the person who administered the medication.
In addition to a doctor, pharmacist, or nurse, a hospital may be liable when problems with its policies, procedures, staffing, training, supervision, medication storage, communication systems, or other patient safety practices contribute to a medication error and resulting injury.
The local Tampa medical malpractice attorneys at Palmer Lopez know how to identify liable parties and build strong claims for patients and families harmed by medication errors throughout Florida. Our attorneys have experience taking on major hospital systems and healthcare providers while maintaining a low-volume practice that allows us to give each of our clients the time and attention they deserve.
If you or a family member suffered serious harm or wrongful death because of a medication error at a Tampa hospital or other healthcare facility, schedule a free consultation with the team at Palmer Lopez today to learn how we can help.
