Four Patients Got the Wrong Drug in Nashville. Ask a Better Question.

On August 14, four patients went to Ascension Saint Thomas Hospital Midtown in Nashville for joint replacement surgery. All four were harmed during the procedure. The hospital has not said how. One family says the drug was potassium chloride instead of the anesthetic. That patient is paralyzed from the chest down.

Why it matters: Spinal anesthesia for a knee or hip replacement is among the most routine things a hospital does. People go in expecting to walk out. Nothing about this failure was exotic, and nothing about it was unique to this hospital: a nearly identical error has been documented repeatedly with a different drug, and the warnings issued about it have not stopped it from recurring.

Driving the news:

• Ascension Saint Thomas says four patients were harmed during an event on August 14, that it self-reported to state regulators the same day, and that it has identified the cause and put corrective safeguards in place.
• The family of Glenda Dorton, 72, of Centerville, Tennessee, told local reporters she was supposed to receive bupivacaine and received potassium instead. Her daughter-in-law, Kristina Dorton, says Glenda has no feeling or movement below her breastbone.
• NewsChannel 5 reports that two of the four patients are paralyzed.
• The Tennessee Health Facilities Commission has investigators on site. It notified the Tennessee Bureau of Investigation on Friday evening, and the TBI says its investigation is active and ongoing.
• Metro Police and the Davidson County District Attorney's Office both said they have nothing open at this point, and there are no current indications the event was intentional.

Update, August 21: NewsChannel 5 Investigates reported that the mix-up happened in the pharmacy, where the syringes used for these procedures were filled with potassium instead of bupivacaine. The station attributed that to what it had been told, not to a hospital confirmation, and Ascension has not said so publicly. If it holds up, it answers the question I raise below about a shared upstream source, and it moves the focus from the operating room to the pharmacy's fill and check steps.

What we don't know: whether the other three patients received the same drug, what quantity was given, what product and what container were involved, and what happened in the fill and check steps that put the wrong drug in a syringe.

One discrepancy worth flagging: some outlets describe a spinal injection for anesthesia and at least one describes an epidural. Those are different procedures. I have not seen the hospital confirm either.

The number that matters is four

One patient getting the wrong drug is an error. Four patients, on one day, in one service line, is a different animal.

Four clinicians independently making the same mistake on the same morning is not a plausible story. Four patients reached through a shared upstream source is very plausible: a bin or tray stocked with the wrong product, a batch drawn from the wrong container, a delivery placed where the anesthetic belongs.

That was inference when I first wrote this. The pharmacy reporting, if confirmed, turns it into something closer to established fact. Either way, it is the inference that should drive what other hospitals do this week, because it points at stocking, supply, and preparation rather than at individual attention (or blame).

One sentence in the hospital's statement deserves a closer look. Leaders said they identified the cause within days. Identifying a cause within days is not the same as completing a root cause analysis. Finding the last person to touch the syringe would not explain the conditions that made four patients reachable through a single point of failure.

They may have gone much deeper. Publishing what they found would show us.

This is not a look-alike, sound-alike name problem

“Potassium chloride” and “bupivacaine” share no letters, no syllables, no stem. Tall man lettering does nothing here. ISMP's look-alike name list does nothing here. None of the safeguards built around look-alike and sound-alike names addresses this failure mode.

What we are looking at, if the family's account holds, is a container problem. Two clear, colorless solutions in small glass containers, sitting somewhere in physical reach of each other.

And the packaging is where this gets interesting, because on paper, the differentiation is aggressive. Potassium chloride concentrate is supplied as 2 mEq/mL in single-dose vials, and after the deaths of the 1990s, USP required the cap and the overseal to be black and to carry the words “Must Be Diluted”. The package insert says plainly that direct patient injection at that concentration may be instantaneously fatal.

So if standard commercial product was involved, the warning existed, in the design, in black, and it did not work. That is the argument for why labels and warnings sit near the bottom of the hierarchy of controls. A black cap is not a substitute for keeping the drug out of the room.

There is a second possibility I want to name as a question rather than a claim. ISMP has warned that during shortages, outsourcing facilities have supplied compounded potassium chloride concentrate that is not subject to the same labeling rules – in one case, an amber vial with a black cap but no black ferrule, which, once opened, looked much like that same compounder's calcium chloride. That is a documented path by which a heavily differentiated product becomes an undifferentiated one. What product, from what supplier, in what container, is a question the investigation should answer.

The same error, with a different drug

There is a recurring wrong-drug, wrong-route error in anesthesia where tranexamic acid gets injected intrathecally instead of bupivacaine.

The FDA alerted clinicians in December 2020, then said again in February 2025 that reports keep arriving, with outcomes including death, disability, and prolonged hospitalization. APSF puts mortality around 50 percent. ISMP documented cases in a knee surgery, a hip replacement, and a bilateral knee replacement, each involving a container mix-up.

Every one of those was a joint replacement. That is not a coincidence. Tranexamic acid is routinely used in joint replacement, so it is physically present in the same room as the spinal tray.

That raises a question about Nashville. With tranexamic acid, there is an obvious reason the wrong drug is in the room. Concentrated potassium has no business being anywhere near a neuraxial setup. If it was there, that is a supply chain and storage question, that would make this worse than the tranexamic acid cases, not another instance of them.

The FDA alert is also a reminder that an alert is not a control. The notification system fired correctly. It fired twice. Patients kept getting hurt for more than four years.

The investigation may be justified. The chilling effect is still real.

The TBI opening a file here is defensible. Four patients, one day, one wrong drug is exactly the fact pattern where you have to rule out a deliberate act. Tampering and diversion are real. An investigator who did not look would be doing the job badly.

So I am not going to write “they are criminalizing error again.” That argument collapses if nobody is ever charged.

The problem is what Tennessee taught everyone with the RaDonda Vaught prosecution. ISMP called that verdict a threat to patient safety. The possibility of criminal charges can change what people are willing to say long before anybody is actually charged.

Yes, but: compared to Vanderbilt in 2017, this hospital has behaved differently, and I will say so. A named CEO apologized in writing within four days and used the words harm and sorry, without the passive voice and without “if anyone was affected.” Leaders met with each family. The hospital reported to the state the day it happened. In the Vaught case, the initial report did not disclose the error and the cause of death was recorded as natural.

Credit the speed and the naming. Same-day reporting to regulators is largely a compliance obligation, so credit that less. And none of it extends to the silence about mechanism, which is the part that would prevent the next one.

“Patient privacy” is doing three different jobs

When a hospital says it cannot discuss the details, three separate things get bundled into one word.

The system description. Which drug, which storage location, which preparation step, what changed afterward. None of that requires identifying a patient or disclosing their protected health information. “Patient privacy” does not explain why those system details must remain secret.

The individual patient's clinical detail. This is real PHI. It belongs to the patient, not to the hospital. Which is what makes the Nashville situation strange: the Dorton family has gone public, by name, in detail, on television. A signed authorization would remove the patient-privacy barrier entirely. Hospitals almost never ask for one, even when the patient or family is already discussing the case publicly.

Reputation and liability. These concerns can get bundled into “privacy,” too: peer review privilege, brand, market position, and the reflex that saying less is safer.

That asymmetry is hard to defend. The same organizations that cite privacy to withhold will release clinical detail when it helps them, usually to suggest the patient was sicker or an outlier. Privacy turns out to be waivable when it is exculpatory.

Better than “could this happen here”: show me that it cannot

This is the part I actually care about, and none of it requires the investigation to finish.

Walk the physical space. The block cart, the anesthesia workstation drawers, the automated dispensing cabinet in the OR, and any tray or syringe that arrives pre-filled from pharmacy. Ask what concentrated electrolytes are physically reachable from where neuraxial drugs get drawn.

Then change the question you ask. “Could this happen here?” invites a reassuring answer, and you will get one.

Ask instead: show me that it cannot.

That requires evidence, not reassurance. It is checkable in an afternoon, and the answer is either a demonstration or a project.

The durable controls, strongest first:

• Remove concentrated potassium from procedural areas entirely. This was the answer in the 1990s. Verify it rather than assuming it.
• Move to manufacturer-prepared, ready-to-administer neuraxial anesthetics so nobody is drawing from a vial at the point of care.
• Close the barcode gap. Anesthesia drug preparation is still the largest area in most hospitals where a clinician selects, draws, labels, and gives a drug without a scan.
• Independent verification before neuraxial injection of any high-alert drug, with the understanding that a second check catches less than people believe. In the Cardiff insulin case I wrote about last week, the second nurse did her check correctly and the patient still received the wrong drug.

One precision point, because it is about to come up in every discussion of this case. NRFit, the ISO 80369-6 neuraxial connector, is a genuine forcing function and I am in favor of it. But it prevents wrong-route misconnection, like IV tubing joined to a spinal needle. It does not stop anyone from filling a neuraxial syringe with the wrong drug out of a vial, because vials do not have connectors. That is true whether the filling happens at the bedside or in the pharmacy. If Nashville was a container selection error, NRFit would not have caught it.

The ask

Ascension operates a large multi-state system. It could push what it learned to every one of its own hospitals within 24 hours, and publish it externally within weeks, without naming a single patient.

That is the concrete thing to ask for. Not more transparency in general. A specific finding, distributed fast, in a form an OR leader can act on.

If this post reaches more operating room leaders this week than the formal safety infrastructure does, that is not a compliment to the blog.

Go deeper

• Woman says mother-in-law paralyzed after receiving potassium during surgery – WKRN News 2
• TBI investigating drug mix-up at Nashville hospital – NewsChannel 5
• State health inspectors investigating Nashville hospital – WSMV
• FDA alert on medication errors with tranexamic acid
• APSF: unraveling a recurrent wrong-drug, wrong-route error
• ISMP: safe handling of concentrated electrolyte products from outsourcing facilities
• An Insulin Error Killed a Hospital Patient. How Does Every Other Hospital Learn From It?
• What If Every Hospital Learned From Every Other Hospital's Safety Incidents?

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