NASHVILLE, Tenn. (WTVF) — Last week we showed you the state's report into the recent medication mix-up at Ascension Saint Thomas Midtown. You'll remember four patients who went in for routine surgeries got the wrong medication and suffered horrific complications.
As bad as the state's report may have looked to most of us, we wanted the perspective of someone who truly understands all of the medical jargon throughout the text. So we talked with someone who has read plenty of these sorts of reports to get his reaction.
"It's something that I have never dealt with in my 30 years of practice to see something that bad," attorney Clint Kelly told NewsChannel5 Investigates.
Kelly, who specializes in medical malpractice, described what happened at Ascension Saint Thomas Midtown as the "perfect storm."
"It's the worst kind of care. It's the worst kind of tragedy," he stated.
Late last week, the state released an 80-page report on the drug mix-up in the hospital pharmacy on August 14 that left four patients critically injured, and at least two of them paralyzed, after they were injected in their spines with potassium phosphate rather than a standard anesthetic during what was supposed to be routine joint replacement surgeries.
Investigators gave a long list of how and where the hospital failed to ensure patient safety, both before and after the drug mix-up, writing, "These failures created a culture of overall noncompliance."
Kelly said these types of issues described by state regulators don't just pop up overnight.
"In my opinion, St. Thomas has been getting away with this for a long time. They've been getting lucky," Kelly suggested.
The problems, according to the investigation, started in the pharmacy where technicians who were preparing the drugs were able to "override"..."the system" that's supposed to catch mistakes like these...and there was no "oversight by a (the) Pharmacist on duty."
Investigators also found the hospital "failed to ensure pharmacy personnel were adequately trained and competent in medication preparation processes."
And the investigation revealed that so-called high-alert and potentially more dangerous medications like potassium were not separated from other drugs or more clearly marked.
"It just seems there were dangerous risks that were unnecessary. It doesn't have to happen this way," Kelly said.
He said many hospitals buy these medicines pre-packaged by the drug manufacturer, smaller vials the anesthesiologists can grab and prepare themselves in the operating room, eliminating the need for the pharmacy and the inherent risks there.
"If you have it already pre-made, you don't have to go through that process. It's easy to put into the computer. It's easy to know what you got and you've got the right patient. Very easy. It's hard to make a mistake," Kelly explained.
But those pre-made vials, he pointed out, are also more expensive, which could be why Ascension Saint Thomas has its own in-house pharmacy prepare the drugs.
"It's cheaper to do it that way. It's cheaper to get something in bulk. It's like buying a pound of sugar versus a little small sugar pack. There's an expense to getting it reduced in size and ease of use versus buying it in bulk and drawing it out in bulk and serving it that way," Kelly stated.
Despite all of the problems found in the pharmacy after the drug mix-up, we now know that when the Tennessee Board of Pharmacy visited the Midtown location back in February, the facility passed its inspection and inspectors found the pharmacy's drugs stored properly and apparently separated as they should have been.
"How do you go from that (passing an inspection) in February to what happened (the drug mix-up) here in August?" Kelly wondered aloud, adding, "You have to believe that over the last eight months, the entire hospital pharmacy systems collapsed? That makes no sense, does it?"
Kelly continued, "If you look at the way this (the drug mix-up) went down, you have to believe that this has been a practice that's been going on for some period of time, particularly when it goes to overriding the computer safety system."
After the drug mix-up two weeks ago, Ascension Saint Thomas Midtown was put under what's known as "immediate jeopardy" by the state, meaning conditions at the hospital put patients' lives in danger.
And the hospital repeatedly failed to come up with an acceptable plan to fix the problems.
"That is damning," Kelly remarked.
He then suggested that if that same sort of thing had happened in a nursing home,
"You'd expect them to be shut down."
"At least until they could prove that they had fixed things?" we asked.
"Until they've remediated the problem and can be confident that whatever the issue is they've found has been fixed," Kelly replied.
But it appears that never happened at the Midtown hospital.
"That's inexcusable," Kelly said.
So what is the current status of the Midtown location? Is it still under immediate jeopardy? Did it ever develop a safety plan that satisfied state regulators?
We wish we had the answers to all of those questions. We have been asking both the state and the hospital those questions now for days. We have gotten no response from the hospital, while the Executive Director of the state's Health Facilities Commission sent an email late Monday afternoon saying he was unable to comment. None of that is reassuring for anyone who might need medical or surgical care there.
As far as the drugs prepared by the manufacturer and by hospital pharmacies, we asked the other major hospitals in the area what they do.
TriStar said all 10 of its hospitals in Middle Tennessee, including Centennial, Skyline, Summit and Southern Hills in Nashville, use those pre-packaged single-dose vials that the anesthesiologist pulls and prepares themselves. They do not have their pharmacy prepare it.
We also reached out to Vanderbilt Medical Center. We are still waiting for a reply.
To read the full state report:
Tennessee State Health Facilities Commission Report on Ascension Saint Thomas Midtown mistake
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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