Our hearts remain entirely with the four patients and families impacted by the recent event at Ascension Saint Thomas Hospital Midtown. On behalf of our leadership and care teams, we extend our deepest apologies for the harm caused. Our clinical teams continue to provide dedicated care to these four individuals, and we are offering our full support and spiritual care resources to their loved ones.
To provide additional information regarding this event, on Friday, August 14, an isolated medication error occurred in our pharmacy impacting four joint replacement patients at our Midtown campus. The patients mistakenly received potassium phosphate, instead of the intended anesthetic medication, mepivacaine. The four patients experienced adverse health reactions and received immediate medical care. A comprehensive review confirmed that no other patients were affected.
Upon identifying the error on August 14, hospital leadership self-reported the event to state regulators. We have since implemented several changes to our pharmacy processes and safety protocols targeted at preventing this error.
Specifically, Midtown has implemented additional physical, technological, and clinical safeguards. The following changes are designed to address medication risks and uphold the standards of safety for our patients and teams:
- 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.
Following our self-report, Ascension Saint Thomas continues to collaborate with state and federal officials to ensure a safe environment for our patients. Additionally, we have engaged independent, third-party quality experts to review and validate our mitigation plans.
Providing safe, high-quality, patient-centered care is at the core of our mission. Any gap in meeting that standard receives our immediate, uncompromising attention. We remain steadfastly committed to supporting those affected and upholding safety standards for every person who trusts us with their care.
