An independent pharmacy expert says the medication error that harmed four patients at Ascension Saint Thomas Midtown was not the result of a single mistake, but a larger breakdown in the hospital’s medication safety system. Dr. Tracy Skaer, a licensed pharmacist and professor emeritus of pharmacotherapy at Washington State University, reviewed portions of the state’s 80-page investigation for news outlets this week. The report details multiple points where the error could have been caught before four joint replacement patients received potassium phosphate instead of the intended anesthetic, mepivacaine.
Multiple Safeguards Failed in Pharmacy
The state report lays out a chain of events inside the hospital pharmacy. A pharmacy technician initially selected the correct medication, mepivacaine. But after realizing another vial was needed, the technician went back to the medication storage area and instead retrieved potassium phosphate. The report says the potassium phosphate would not scan. Despite that warning, the process continued. Another technician later drew potassium phosphate into five syringes and placed labels identifying the drug as mepivacaine on each one.
The syringes then went through another layer of review. Investigators found the pharmacist responsible for approving them did not bring the bin containing the filled syringes to the workstation for a direct physical comparison. Skaer said each step should provide another opportunity to catch a mistake before a medication reaches a patient. People get complacent with the technology available and miss simple things. There should be safeguards, but the errors snowball.
Barcode System Bypass Risks
One finding that stood out to Skaer involved the hospital’s technology. Investigators found pharmacy technicians could override the barcode scanning process and manually enter information without pharmacist verification. The state concluded that allowed multiple opportunities to detect an incorrect medication to be bypassed. Skaer said if a medication does not scan, that should prompt staff to stop and figure out why rather than work around the warning. If it doesn’t scan, they should be talking to the pharmacist.
The investigation also found one technician involved had already been receiving additional coaching. According to the report, the technician was given a coaching feedback form the morning of August 13. This occurred one day before the medication was administered to the patients. The concerns included difficulty following the IV-room workflow, medication calculations and a continued need for supervision and repeated coaching. Skaer said that raises questions about whether the technician should have been working in that part of the pharmacy without further training. However, she stressed that the investigation points to failures beyond any one employee.
Clinical Response and Future Hospital Protocols
Skaer also pointed to what happened after the medication reached the patients. The state found Ascension failed to provide a timely, organized and effective clinical response as the four patients experienced worsening complications. Skaer said when a patient experiences an unexpected reaction, medical teams need to quickly question whether a medication error could be responsible. The sooner you raise the flag, the better. They do happen. They will happen, but you need to have a rapid response.
Ascension has announced several changes since the August 14 error, including separating and more clearly marking high-alert medications. They now require staff to stop when certain spinal medications trigger a scanning alert and have added another pharmacist check. Skaer called those safeguards a start but said the hospital should examine its broader medication system. She said that should include reviewing policies, staff training, how high-risk medications are stored and what employees are required to do when technology flags a problem. Ascension said in response to the state report that it takes the findings seriously and is continuing to cooperate with state and federal surveyors.