Nashville, Tenn.-based Ascension Saint Thomas Hospital Midtown implemented new safeguards for spinal medications after four joint replacement patients received the wrong medication.
The patients mistakenly received potassium phosphate instead of the intended anesthetic medication, mepivacaine, Aug. 14. All four experienced adverse health reactions and received immediate medical care. The hospital said a review confirmed no other patients were affected.
Ascension Saint Thomas implemented a hard-stop and escalation process requiring independent verification for spinal medication scan alerts. Spinal medicine workflows also now require a second trained pharmacist to perform final visual and physical checks. The hospital also separated high-alert medications, including mepivacaine, into distinctly marked storage locations, according to an Aug. 21 news release.
Hospital leadership self-reported the medication error to state regulators Aug. 14. The Tennessee Bureau of Investigation opened an investigation that evening after the Tennessee Healthcare Facilities Commission informed the agency of the event. Commission staff are also investigating and coordinating with CMS.
Ascension Saint Thomas has also engaged independent quality experts to review its mitigation plans, according to the release.
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