A state investigation details the drug mix-up at Ascension Saint Thomas Midtown last month that paralyzed four patients.
The hospital had already publicly confirmed its staff had accidentally given orthopedic surgery patients potassium phosphate in their epidural injections instead of an anesthetic. And for weeks, bits of information have trickled into public view. TV news stations like News Channel 5 and WSMV were among the first on the story, publishing interviews with patients’ families. Then the hospital issued statements with some specifics.
But this report offers a level of detail unavailable to the public until now. It compiled interviews with the staff involved in the accident. Investigators reviewed surveillance footage of the staff while they made the mistakes. They spoke at length with patients, as well as with experts who weighed in on what should have happened differently.
The thrust of their findings: Humans made mistakes, but there were opportunities to catch and prevent those mistakes. System-level failures kept that from happening.
The hospital system declined to comment and pointed to its ongoing response webpage.
Events within the pharmacy on Aug. 13
It all started in the pharmacy.
A technician was trying to grab an anesthetic called mepivacaine. It’s a clear liquid in a small glass vial. It has a white label with black lettering and yellow rectangles. All of that is also true of the vials of potassium phosphate. The report says this is an understandable, even foreseeable, mistake.
Because of that easy confusion, the report says hospitals generally put warning labels on medications like potassium phosphate: “high-alert drugs” that can have lethal side effects if misadministered. The report also notes that potassium phosphate should only be administered when diluted through an IV. It says hospitals tend to store such concentrated medications far away from those to be injected directly.
The report says the pharmacy tech had to scan the medications into a computer system before continuing. When the person did so, it appeared not to work. The tech said in a later interview that the computer allowed typing in the information manually.
“This failure permitted pharmacy technicians the ability to override the barcode scanning process and manually enter vial information without pharmacist verification, which allowed omission of critical vial identifying information… and circumvent multiple opportunities to detect an incorrect medication before it was prepared, verified, dispensed, and administered,” the report reads.
The vials, labels and syringes were handed off to another pair of pharmacy techs. Neither of them noticed the vials were potassium phosphate, the report says. One of those techs filled the syringes with the potassium, taking pictures of each step along the way. That person then tossed the vials into the discard bin and brought the syringes to the pharmacist.
The pharmacist reviewed the pictures and records for 29 seconds, according to the report, then signed off and attached labels for the anesthetic. The report also notes that the order had requested six syringes, not five, and the pharmacist didn’t notice.
“The Director of Pharmacy stated that this had been a systemic problem in the pharmacy verification process,” the report reads.
Patient perspectives
The report says seven people were getting similar outpatient surgeries for joint replacement that day, but only four of them ended up getting potassium injections.
The report details each of the four patients’ experiences, with timelines of events. Each had surgeries scheduled for the morning of Aug. 14. Nearly all of them vocalized that something was wrong when the spinal injections were given.
“When they were pushing the IV medication, I screamed something is wrong,” one of the patients later told investigators. “I have never felt a burn like that, a burning in my spine like a liquid hell.”
Two of the patients had their surgeries called off. One was given general anesthesia instead.
The first patient to receive potassium complained of pain so vocally that the procedure was canceled. Shortly after, he said he couldn’t feel or move his legs. Around 8 a.m., the anesthesiologist said they were “not concerned about this at this time,” and declined support from a hospitalist. By 9:45 a.m., the patient reported no sensation from the abdomen down. At 11 a.m., the patient was intubated and taken to the ICU. The patient was put on life support, and the report says that, as of investigators’ last check-in on Aug. 21, the patient was still on life support.
The second patient entered the operating room just before 8 a.m. and didn’t complain of pain during the injection process, although several staffers who were later interviewed said she reported a burning sensation. At 10 a.m., she reported no pain to the medical staff. But it increased to a 5 out of 10 a few minutes later. By 11 a.m., she was rating her pain in both arms at a 10.
“Patient #2 stated she was moved to Hospital #1’s ICU, but no explanation was provided as to why she was being taken to the ICU,” the report reads. “Patient #2 stated in ICU the itching became worse and she experienced ‘crazy pain…unbearable…’ She stated it appeared the staff did not know what to do and were standing around wondering what to do next.”
The report says the hospital’s chief medical officer and a neurologist told her they found a treatment option online and that they were going to carry it out. She was put under.
“Patient #2 stated when she woke up from sedation the itching and burning symptoms were gone, but she had no feeling from her breasts down,” the report reads.
As of an interview on Aug. 21, the patient hadn’t regained feeling.
The other two stories were similar. As of last contact with investigators, neither had regained feeling in their lower body.
“Immediate jeopardies”
The report chastised the hospital for delaying treatment of the patients. Eventually, each of them had a spinal lavage — basically a washout in which medical staff remove some spinal fluid and replace it with saline. The report notes that this procedure was delivered hours after the potassium injection, after the patients were taken by ambulance from hospital #1 to hospital #2. This appears to refer to Ascension Saint Thomas Midtown and Ascension Saint Thomas West.
“The hospital failed to ensure timely assessment, reassessment, intervention and coordination of identified clinical abnormalities, development of an appropriate treatment plan, and timely implementation of treatment which resulted in unexpected and progressive neurological, respiratory, and hemodynamic decline” for the four patients, the report says.
The report also found that the anesthesiologist who injected the patients was not put on leave or under peer review. They were still on the schedule for several days after the event.
In total, the report issued three “immediate jeopardies” for the hospital, which is the most severe form of citation. They focused on the pharmacy, surgical services and governing body. The hospital pitched three corrective action plans, the report reads, and each was rejected.
“Because the hospital had not demonstrated that sufficient corrective actions had been implemented to remove the Conditions constituting the Immediate Jeopardies, the survey team exited the hospital on 08/21/2026 with all three Immediate Jeopardies ongoing,” the report reads.
How the report came to be
The report was compiled by the Tennessee Health Facilities Commission. That agency works with the Centers for Medicare and Medicaid Services to oversee health providers like hospitals and nursing homes. When someone files a complaint against a provider with CMS, it’s the Health Facilities Commission that carries out the investigation on the federal government’s behalf.
In a statement online, Ascension Saint Thomas self-reported the incident. The federal government says for investigations this serious, the commission has to get to work within two business days of receiving the complaint, according to an audit by the comptroller’s office.
Aftermath
Nearly a week after the incident, investigators found the medication still didn’t have a warning label on it.
“Observations in the 2nd floor pharmacy …on 08/20/2026 at approximately 10:30 AM, revealed Potassium Phosphate was stored on the pharmacy wall with other medication vials and had not been identified by labeling or visual management cues to alert pharmacy staff that it was a high-alert medication,” the report reads.
On Aug. 21, Ascension Saint Thomas posted on its website, saying it had updated pharmacy policies to hedge against similar mistakes. It reads in part:
- Isolated Medication Storage: High-alert medications, including mepivacaine, are stored in separate, distinctly marked locations to eliminate selection errors.
- Mandatory Hard-Stop & Escalation: Implement process to stop and resolve, through independent verification, for any spinal medication scan alert.
- Independent Dual Verification: Spinal medicine workflows now require a second trained pharmacist to perform final visual and physical checks.
The Tennessee Bureau of Investigation is still assessing the situation. It’s unclear whether the agency will pursue criminal charges.
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