Medication Mix-Up at Ascension Saint Thomas Hospital Midtown Leaves 72-Year-Old Woman Paralyzed, Four Patients Harmed
核心洞察
A 72-year-old woman, Glenda Dorton, was left paralyzed from the chest down after allegedly receiving potassium chloride instead of bupivacaine in an epidural during knee replacement surgery at Ascension Saint Thomas Hospital Midtown (搜索).
Ascension Saint Thomas confirmed at least four patients were harmed in an undisclosed "event" and reported the incident to state regulators on the day it occurred.
Hospital President and CEO Dr. Shubhada Jagasia publicly apologized and stated the cause was quickly identified with "corrective safeguards" implemented.
A medication error at Ascension Saint Thomas Hospital Midtown (搜索) in Nashville, Tennessee, has left a 72-year-old woman paralyzed from the chest down, with the hospital confirming that at least four patients were harmed in an undisclosed "event."
Glenda Dorton was scheduled for a knee replacement surgery at the hospital on Aug. 14, according to her family. The family said the epidural she was supposed to receive to help control pain during the procedure was filled with potassium chloride instead of bupivacaine.
Dorton's daughter-in-law, Kristina Buell, described the immediate aftermath when Dorton woke up. "She was having a reaction; she was itchy. She said her whole body was burning, and she couldn't feel her legs," Buell said. Dorton is now paralyzed from the chest down and remains in the intensive care unit, with her family hoping doctors can determine whether any of the damage can be reversed.
Clinical Severity of the Error
Dr. Matthew Byrnes, a surgeon at Catalina Island Health in California, explained the danger posed by potassium chloride when administered incorrectly. He noted that patients are sometimes given potassium chloride to steady their heart rhythm, but it must be administered as a slow drip to prevent complications.
"You can't go any faster than that or it would cause cardiac problems and if the potassium was to get out of the vein, then you could chew up the tissue around it. So, infusing it straight into the spine you can imagine it destroying the spinal cord," Byrnes said.
Potassium chloride can be extremely dangerous when administered incorrectly. It has also been used as part of Tennessee's lethal-injection protocol in the past, although the state now uses a different drug for executions.
Hospital Response and Investigation
Ascension Saint Thomas said it reported the incident to state regulators on the day it happened and immediately launched an investigation. Hospital President and CEO Dr. Shubhada Jagasia said the cause of the incident was quickly identified and that the hospital "implemented corrective safeguards."
"On behalf of our leadership and care teams, I am deeply sorry for the harm caused to our patients," Jagasia said. "We have met directly with each of the families to express our deep support, connected them with spiritual care teams, and ensured they have access to all appropriate resources and ongoing care needed."
Jagasia added, "Providing safe, high-quality care is at the core of everything we do, and any gap in meeting that standard receives our immediate, uncompromising attention."
The hospital's clinical teams said they are following enhanced safety protocols in the wake of the incident. Ascension has not publicly released the specific cause of the medication mix-up or explained how the wrong drug was administered, citing patient privacy for the other three affected patients.
Preventing Future Errors
Dr. Byrnes emphasized that hospitals should follow standard protocols to prevent such errors, including labeling every medication prior to surgery.
"If you didn't have it labeled, you wouldn't know the difference between 95 percent of medications. They all look like water. There's one that looks like milk. There's a few with a yellow tint," Byrnes said. "You have to look at the details closely and look at what you're infusing before you put it in. The last person standing has the ultimate responsibility."
Family Focused on Recovery
For Dorton's family, the investigation is only part of the story. Buell said Dorton was very active and had been putting off the surgery because she did not want the downtime that comes with it, and that the mistake has changed their lives.
"We're hoping that we can give her the care she needs. This is the rest of her life, and she still has a lot of life to live. So, we're just hoping to make that as good as possible," Buell said.
The family says Dorton remains in the ICU and is surrounded by loved ones as they wait for answers about what comes next.