NASHVILLE, Tenn. (WTVF) — We are getting stunning new details about that catastrophic drug mix-up at Ascension Saint Thomas Midtown two weeks ago.
State regulators have just released their initial investigative report into what went wrong before, during, and after four patients got the wrong medication injected into their spines, causing horrific complications.
It turns out, it wasn't just one problem, but many.
In fact, the state brought in an expert during its investigation who said one failure after another by pharmacy employees and multiple systemic failures led to this terrible tragedy.
The 80-page report is our first real look at exactly what went wrong at Ascension Saint Thomas Midtown on August 14th. And according to the report just released by the Tennessee Health Facilities Commission, a lot went wrong.
In fact, shortly after state investigators began their work Sunday, August 16th, they found three instances of "immediate jeopardy," meaning conditions at the hospital that put patients' lives in danger.
Investigators cited problems in the hospital pharmacy, surgery services, and even the hospital's governing body, meaning management, for creating an environment where it was possible for four patients who went in for routine joint replacement surgeries to be injected in their spines with potassium phosphate rather than a standard anesthetic.
NewsChannel 5 Investigates found video giving us our first look inside the pharmacy where one drug was exchanged for the other on the pharmacy's own social media account. And, it was in this space, according to investigators, that three separate pharmacy technicians failed to notice the mix-up and were able to "override"..."the pharmacy system" that's supposed to catch mistakes like these, and that there was no "oversight by a (the) Pharmacist on duty."
Investigators found the hospital "failed to ensure pharmacy personnel were adequately trained and competent in medication preparation processes."
In fact, we learn in the report, that one of the technicians was new to the job and that management had, just the day before, expressed concerns about the tech's "difficulty understanding common...medication terminology...and processing medication labels."
The state's investigative team also expressed concerns about how so-called high-alert and potentially more dangerous medications were not separated from other drugs and better marked.
And yet when regulators went back to the pharmacy two days and even six days later, they found "the potassium was still on the wall with other medicines and not identified."
But it was not just in the pharmacy where the state found problems. The surgery team was also called out in the report for what happened after the four patients got the potassium which almost immediately began to attack their spinal cords, causing, as at least one patient described, "burning" and "excruciating pain."
Investigators said the hospital then failed to implement a timely and effective treatment plan "which resulted in unexpected and progressive neurological, respiratory, and hemodynamic decline in all four patients.
The report cites numerous medical studies on how to counteract a spinal "injection of excess or (the) wrong drug," yet investigators say Ascension Saint Thomas doctors did not immediately jump on these recommended treatments.
In fact one patient's family member said a hospital staff member told him, "We do not know how to handle this."
And while the hospital claimed that patient did initially receive that recommended treatment, the family insisted the patient did not and there's no record of it in his medical chart.
So who's to blame? State investigators put a lot of that on hospital management, citing 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."
Ascension Saint Thomas said in a new statement, "We take the survey findings extremely seriously and are continuing to cooperate with state and federal surveyors to ensure a safe environment for our patients."
Yet, it appears the hospital is still not "safe" enough, according to the state of Tennessee.
The hospital submitted a plan to address the safety problems on August 18 which was "deemed unacceptable." A second report the next day was also "unacceptable." And later, a third plan was also found to be "unacceptable" and without enough information to show that corrective steps had been taken to ensure patient safety.
When state regulators left the hospital a week ago, the safety plan had still not been accepted by the state.
We asked both the state and the hospital if a new safety plan has since been accepted. We did not get a reply from either.
Something else that jumped out of the report was that it turns out that five syringes had actually been prepared with the wrong medication. But only four ended up being used. There were a number of other surgeries scheduled that day. Thank goodness they finally realized what was going on and did not use that final shot.
The state's report also shares new information about the patients.
It confirmed that one is paralyzed from the chest down. That appears to be 72-year-old Glenda Dorton from Centerville.
We know a second patient is also paralyzed. That's the patient who went into cardiac arrest after getting his injection.
A third patient, the report said, can move her toes, but can't lift her legs and kept asking, "Why can't I move my legs?"
All three are now being transferred to spinal rehabilitation facilities for further treatment.
The fourth patient remains in the most serious condition. Shortly after the incident, the patient was put on ECMO which is a machine that runs the patient's heart and respiratory functions. When the report was written, this patient was still on ECMO, obviously in very critical condition.
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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