NASHVILLE, Tenn. (WTVF) — Ascension Saint Thomas Midtown now says it has taken steps to prevent another drug mix-up in its pharmacy.
This comes after four patients had the wrong medications injected into their spines, causing serious health complications.
At least one woman was left paralyzed, according to her family.
Late last week, the hospital announced that it had made changes in its pharmacy and added new safeguards.
But there are questions now about why these measures were not already in place.
"It's sad that something like this would happen in today's healthcare," Dr. Stephen Eckel said.
Like so many, Eckel was stunned to hear how four patients at Ascension Saint Thomas Midtown received the wrong medication when they went in for routine joint replacement surgeries August 14th.
Last Friday, the hospital acknowledged that a mix-up in the pharmacy led to four patients being injected not with mepivacaine, a standard anesthetic, but potassium phosphate, which if not diluted properly can cause catastrophic complications.
And while the two drugs can come in different types of packaging, photos of two vials of these medicines, which we do not know if these are the types of vials that were confused, do at least show how similar the two medications can appear.
Dr. Eckel explained, "I think we have come to recognize in healthcare, especially in pharmacy, that look alike and sound alike medications are prone to cause issues and problems."
But Eckel, who teaches at the University of North Carolina's Eshelman School of Pharmacy and is also a longtime hospital pharmacy administrator, said, that's why multiple layers of safeguards are so important, especially when dealing with a potentially high-risk medication like potassium.
He suggested safeguards such as keeping these drugs in a separate area, away from the other medications which forces pharmacy employees to be more deliberate when handling them.
"We want to make sure that when they pause and are using them that they think and say, 'Okay, I need to make sure this is being used correctly,'" Dr. Eckel explained.
Also highly recommended: barcoding technology that the employee uses to scan both the drug and the hospital label and gives an alert if the two do not match.
"Would you say most hospitals already have these in place?" NewsChannel5 Investigates asked Dr. Eckel.
"I know it's what we advocate for and what we teach and educate individuals, organizations to be doing," he replied.
But those safety protocols were apparently not in place or at least being followed at the Nashville hospital when the medication mistake happened because these same safeguards are exactly what Ascension Saint Thomas announced it was implementing in its pharmacy late last Friday, a week after the mix-up.
"So it sounds like these sorts of steps should already have been in place?" we asked Dr. Eckel.
"Those are steps that we should be using in the care of patients, correct," he answered.
Nothing, he said, will change what happened at the hospital on August 14th, but hopefully, the changes being made will make a difference.
"The bottom line is we want to make sure that this does not happen again in this hospital or any other hospital. And so, this should be a wake-up call for every hospital to go back and evaluate — do they have the best practices going forward?" Dr. Eckel suggested.
Ascension Saint Thomas also said in its statement announcing the changes that all spinal medicine must now be double checked by a second trained pharmacist.
And the hospital said that it brought in independent, third-party experts to review and validate these new safety measures.
If you or someone you know was affected by this medical mistake, I'd like to hear from you. Please email me at Jennifer.Kraus@newschannel5.com.
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