An 80-page report revealed more details about a ‘pharmacy error’ that sent multiple patients into cardiac arrest at a Nashville hospital.
At least two patients are paralyzed, and one was put on a ventilator at Ascension Saint Thomas Midtown Hospital on August 14 after they were given the wrong medication prior to surgery.
The four patients were reportedly given potassium instead of an anesthetic. The dangerous mix-up happened at the hospital’s in-house pharmacy.
Too much potassium administered too quickly can stop a person’s heart, CBS reported.
The Tennessee Bureau of Investigations is now involved in the case.
The hospital said they were “sorry” for injecting the patients with too much potassium.
“Our hearts remain entirely with the four patients and families impacted by the recent event at Ascension Saint Thomas Hospital Midtown,” the hospital said. “On behalf of our leadership and care teams, we extend our deepest apologies for the harm caused.”
Multiple patients at a Nashville hospital are paralyzed after staff accidentally gave them the wrong drugs.
The hospital says they are “sorry” after injecting potassium chloride into the spines of people getting routine joint replacement surgeries.
Hospital staff noticed… pic.twitter.com/ZvzDgx2cdN
— Collin Rugg (@CollinRugg) August 22, 2026
According to WKRN, the Tennessee Health Facilities Commission released an 80-page report releasing its findings after conducting an investigation into the pharmacy errors that resulted in severe injury to multiple patients.
Investigators found that five syringes that were supposed to contain Mepivacaine 2% (an anesthetic) were mistakenly swapped with potassium phosphate the day before surgery. The error passed through preparation, verification, and dispensing, even though three pharmacy technicians and one pharmacist were involved in the process.
According to WKRN, Pharmacy Technician #1 retrieved one vial of the anesthetic, then returned to another storage bin and grabbed a vial of potassium phosphate instead.
The incorrect medication was transferred to the mixing room, where Technician #2 took the potassium and filled five surgical syringes. The syringes were then labeled as Mepivacaine and passed to the pharmacist shortly before 11 am on August 13.
Although the pharmacist reviewed the syringes, the medication was not physically compared with the computer record. The report revealed that the pharmacist took only 29 seconds to verify and approve the medication.
The syringes filled with the wrong medication were subsequently sent from the hospital’s in-house pharmacy to be used on the patients on August 14.
Technician #1 told investigators last week that she “could not say for sure if the vial was Mepivacaine or Potassium Phosphate” and “she wished she had looked more closely at the vials.”
Technician #2 told investigators that she was supervised by Pharmacy Technician #3 that day because she is at the end of her probationary period and had never mixed Mepivacaine 2%.
Technician #3 worked at the hospital the entire day after the surgical patients went into cardiac arrest, even though she was involved in the drug mix-up.
Pharmacy Technician #1 was placed on leave on August 14 pending investigation and said no one from the facility has reached out to him.
When he was asked about the drug mix-up, he stated he “did not know if he needed to talk to the survey team without an attorney…”
The report also details the horrific pain and suffering that the patients experienced after the wrong medication was administered.
No lawsuits have been filed against Ascension Saint Thomas Hospital Midtown; however, the victims’ families are currently consulting with attorneys.
Click here to read the full 80-page report.
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