State report details pharmacy failures in Nashville hospital medication mix-up
A Tennessee Health Facilities Commission investigation found that four patients at Ascension Saint Thomas Midtown in Nashville received potassium phosphate instead of the intended anesthetic, mepivacaine, during joint-replacement surgeries on Aug. 14, 2026.
The findings, reported Aug. 28, describe a chain of failures during medication selection, preparation and verification. Five syringes were prepared and labeled as mepivacaine before being administered to four of the seven patients scheduled for joint-replacement procedures that day.
What the state report found
According to the state findings, pharmacy staff selected potassium phosphate instead of mepivacaine. The error was not caught by visual inspection, barcode or workflow safeguards, or pharmacist verification before the medication left the pharmacy.
Mepivacaine was the intended anesthetic. Potassium phosphate was the medication administered instead. The report describes multiple missed safeguards rather than a single unexplained labeling error.
The report concerns an incident at Ascension Saint Thomas Midtown in Nashville. It is an investigation report, not a criminal finding or final court determination.
Four patients required higher-level care
The state report says all four affected patients were transferred to higher-level care after the medication error. As of the survey team’s exit on Aug. 21, one patient remained on extracorporeal membrane oxygenation, or ECMO, a form of advanced life support, and three patients had significant lower-extremity neurological impairment, including paralysis and loss of sensation, according to the findings.
Those patient-condition details are attributed to the state report. Earlier local coverage included additional family-reported accounts; those accounts should not be treated as the regulator’s independent clinical assessment.
TBI investigation remains active
The Tennessee Bureau of Investigation confirmed on Aug. 20 that it was examining the medication mix-up. NewsChannel 5 reported that the inquiry remained active and ongoing.
The existence of that investigation does not establish criminal conduct, negligence or legal responsibility. Available reporting has not indicated that the medication error was intentional.
Hospital announces corrective measures
Ascension disclosed the patient reactions on Aug. 21 and said it reported the incident to state regulators. The hospital said it also changed pharmacy processes and safety protocols and hired independent quality experts to review and validate its mitigation plans.
The announced measures include storing high-alert medications, including mepivacaine, in separate and distinctly marked locations; using hard-stop escalation procedures when a spinal-medication scan alert occurs; and requiring an independent second pharmacist to complete final visual and physical checks.
Those are corrective measures announced by the hospital, not proof that the risk has been eliminated. The next significant developments could come from the TBI inquiry, state regulators, the hospital’s quality review, or any civil or administrative proceedings.
Sources
- WKRN — State report details errors in medication mix-up at Ascension Saint Thomas Midtown
- WSMV — 4 patients experienced ‘adverse’ reactions after medication mix-up, Nashville hospital confirms
- NewsChannel 5 — TBI investigating drug mix-up at Nashville hospital
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