What We're Reading: State Report Reveals Critical Pharmacy Failures After Ascension Saint Thomas Medication Error

This week, we are reading an 80-page state investigation report detailing the medication error at Ascension Saint Thomas Hospital Midtown that harmed four surgical patients. The Tennessee Health Facilities Commission's findings reveal multiple safety failures that allowed pharmacy technicians and a pharmacist to administer potassium phosphate instead of the intended local anesthetic, mepivacaine, to patients undergoing joint replacement surgery.

Read the full state report coverage from WKRN

According to the investigation, the error occurred on August 14 when a pharmacy technician retrieved the wrong medication vial, failed to visually inspect it, and prepared five syringes despite scanning irregularities in the hospital's sterile compounding workflow software. The pharmacist's final verification lasted approximately 29 seconds and failed to detect the substitution before the medication was administered.

The state report identified a cascade of failures that allowed the error to reach patients:

• High-alert medications were stored alongside other drugs without adequate labeling or segregation
• The pharmacy's barcode scanning system allowed technicians to override alerts and manually enter medication information
• There were no hard stops when the wrong medication was scanned
• Despite irregularities with scanning and no manufacturer information appearing in the system, the pharmacy technician moved forward with preparation
• A "culture of overreliance on technology" prevented staff from performing basic visual inspections that could have identified the error.

Regulators classified three areas as "Immediate Jeopardy," meaning investigators determined the problems had caused or could cause serious harm or death. The findings involved the hospital's pharmacy, surgical services, and overall oversight. The report also raised concerns about the hospital's response after patients began showing complications, noting that not everyone directly involved was immediately removed from clinical responsibilities while the incident was being investigated.

The Tennessee Bureau of Investigation has opened a criminal investigation into the incident, which is unusual for a hospital medication error and moves the matter beyond an internal quality review. No charges have been filed, and no wrongdoing has been established.

This incident underscores the critical importance of medication safety protocols, pharmacy procedures, and regulatory compliance in healthcare settings. For healthcare professionals, licensed providers, and facilities, understanding your obligations and rights when facing investigations or licensing board complaints is essential.

If you are a healthcare professional in Lebanon or Wilson County facing a licensing investigation, compliance concern, or professional liability issue, Hagar & Phillips is the law firm to contact. Our healthcare law and licensure defense team understands the complex regulatory landscape governing Tennessee hospitals and healthcare facilities. We represent healthcare professionals, licensed providers, and facilities facing investigations, licensing board complaints, and compliance concerns throughout Lebanon, Wilson County, and Middle Tennessee.

With over 40 years of combined experience, Hagar & Phillips has established itself as one of the most trusted healthcare law firms in Wilson County. Our attorneys bring diverse backgrounds in healthcare, emergency medicine, compliance, and civil litigation to every case. We understand the stakes involved when your professional license, career, and reputation are on the line.

Contact Hagar & Phillips at (615) 784-4588 to schedule a consultation with our healthcare law team. 

This article is for general informational purposes only. It is not legal advice and does not create an attorney-client relationship. Medical malpractice and healthcare licensing matters are fact-specific, and Tennessee law may change.

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