Background: Ascension Saint Thomas Hospital Midtown in Nashville, Tennessee (Google Maps). Inset: Glenda Dorton (Facebook/Kristina Dorton).
A woman in Tennessee going into a hospital for a "routine knee replacement" surgery emerged partially paralyzed as pharmacy staff mixed up vials for the procedure, authorities say.
Glenda Dorton, 72, is completely paralyzed from her rib cage down, the woman's daughter-in-law, Kristina Dorton, told regional Fox affiliate WZTV.
At least three other patients were also given the wrong medications at Ascension Saint Thomas Hospital Midtown in Nashville, Tenn., according to a report from the Centers for Medicare and Medicaid Services. The document shared by local NBC affiliate WSMV alleges that "active personnel failures and underlying system-level failures created conditions that allowed the medication error to occur and placed patients at risk for serious injury, impairment, or death."
On Aug. 14, Glenda Dorton went to Ascension Saint Thomas Hospital Midtown for an elective surgery on her knee, Kristina Dorton wrote on social media. However, a procedure that was supposed to be "routine" turned into a tragedy, as the "hospital pharmacy made a catastrophic error, switching the epidural anesthetic for potassium."
"This led to a devastating spinal cord injury, and she has been diagnosed with complete paralysis" at a level around her midsection, the woman's daughter-in-law said. She said the error "also affected 3 other patients who are in similar situations or are not doing as well."
Authorities were called in to investigate, and they released their 80-page report this week. The issues apparently began before Glenda Dorton stepped through the facility's doors.
On Aug. 13, "five syringes of a medication intended for use as a nerve block were incorrectly prepared for intrathecal spinal administration to patients scheduled for elective outpatient orthopedic surgery" the following day, the report states. On Aug. 14, "the medication was inadvertently administered intrathecally to four surgical patients, resulting in immediate and serious patient harm."
All four patients — including Glenda Dorton — had to be transferred "to a higher level of care." Though the report did not state names, the agency said that on Aug. 21, one patient was on life support for their heart and lungs and three others "continued to experience significant lower-extremity neurologic impairment, including paralysis and loss of sensation extending from approximately the mid-abdominal region downward."
Pharmacy staff had reportedly grabbed the wrong vials, and the "medication-preparation error had not been identified during the medication preparation, verification, and dispensing process despite the direct involvement of three Pharmacy Technicians and one Pharmacist," the report went on.
Investigators also spoke with employees at the hospital. One pharmacist was apparently "asked to define the process for taking pictures of the medications" and responded, "I'm going to let the facility define that for you … it changes periodically … they don't like to put stuff in writing so they can say we did it wrong…"
Kristina Dorton said that her mother-in-law was transferred to a research hospital in Chicago, Illinois, "where she will learn how to live her life to the fullest with as few limitations as possible."
"In true Glenda fashion, she is giving the therapists a run for their money, and they are already having [to] come up with more challenging activities for her," she added.
Ascension — the governing body of the hospital — said in a statement on Aug. 21 that "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."
The statement acknowledged that on Aug. 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."
"A comprehensive review confirmed that no other patients were affected," it continued. "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."
Six days later, the hospital system said it received the Centers for Medicare and Medicaid Services report and that their "support for those patients and their families remains unwavering."
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