{"id":829879,"date":"2026-08-29T15:00:14","date_gmt":"2026-08-29T15:00:14","guid":{"rendered":"https:\/\/www.newsbeep.com\/us\/829879\/"},"modified":"2026-08-29T15:00:14","modified_gmt":"2026-08-29T15:00:14","slug":"pharmacy-expert-weighs-in-on-ascension-medication-error-this-is-a-larger-system-error","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/us\/829879\/","title":{"rendered":"Pharmacy expert weighs in on Ascension medication error: “This is a larger system error”"},"content":{"rendered":"

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\u2019s medication safety system.<\/p>\n

Dr. Tracy Skaer, a licensed pharmacist and professor emeritus of pharmacotherapy at Washington State University, reviewed portions of the state\u2019s 80-page investigation for FOX 17 News.<\/p>\n

The report, released this week, details multiple points where the error could have been caught before four joint replacement patients received potassium phosphate instead of the intended anesthetic, mepivacaine.<\/p>\n

\u201cThis is a larger system error,\u201d Skaer said.<\/p>\n

ORIGINAL COVERAGE | Tenn. woman paralyzed after alleged drug mix-up at Nashville hospital, 3 others affected<\/a><\/p>\n

Expert: Multiple safeguards failed<\/p>\n

The state report lays out a chain of events inside the hospital pharmacy.<\/p>\n

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.<\/p>\n

The report says the potassium phosphate would not scan. Despite that warning, the process continued.<\/p>\n

Another technician later drew potassium phosphate into five syringes and placed labels identifying the drug as mepivacaine on each one.<\/p>\n

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.<\/p>\n

Skaer said each step should provide another opportunity to catch a mistake before a medication reaches a patient.<\/p>\n

\u201cPeople get complacent with the technology we have now and they miss simple things like this,\u201d Skaer said. \u201cThere should be safeguards, but somehow it just snowballs.\u201d<\/p>\n<\/p>\n

Barcode system could be bypassed<\/p>\n

One finding that stood out to Skaer involved the hospital\u2019s technology.<\/p>\n

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.<\/p>\n

Skaer said if a medication does not scan, that should prompt staff to stop and figure out why rather than work around the warning.<\/p>\n

\u201cIf it doesn\u2019t scan, they should be talking to the pharmacist,\u201d Skaer said.<\/p>\n

Technician had documented concerns before error<\/p>\n

The investigation also found one technician involved had already been receiving additional coaching.<\/p>\n

According to the report, the technician was given a \u201cCoaching Feedback\u201d form the morning of Aug. 13 \u2014 one day before the medication was administered to the patients.<\/p>\n

The concerns included difficulty following the IV-room workflow, medication calculations and a continued need for supervision and repeated coaching.<\/p>\n

Skaer said that raises questions about whether the technician should have been working in that part of the pharmacy without further training.<\/p>\n

However, she stressed that the investigation points to failures beyond any one employee.<\/p>\n

\u201cIt\u2019s a larger system failure just by virtue of the multiple errors,\u201d Skaer said.<\/p>\n

PREVIOUS COVERAGE | State finds multiple safety failures after Ascension Saint Thomas medication mix-up<\/a><\/p>\n

Expert questions response after patients became sick<\/p>\n

Skaer also pointed to what happened after the medication reached the patients.<\/p>\n

The state found Ascension failed to provide a \u201ctimely, organized, and effective clinical response\u201d as the four patients experienced worsening complications.<\/p>\n

Skaer said when a patient experiences an unexpected reaction, medical teams need to quickly question whether a medication error could be responsible.<\/p>\n

\u201cThe sooner you raise the flag, the better,\u201d Skaer said. \u201cThey do happen. They will happen, but you need to have a rapid response.\u201d<\/p>\n

Are Ascension\u2019s changes enough?<\/p>\n

Ascension has announced several changes since the Aug. 14 error, including separating and more clearly marking high-alert medications, requiring staff to stop when certain spinal medications trigger a scanning alert and adding another pharmacist check.<\/p>\n

Skaer called those safeguards a start but said the hospital should examine its broader medication system, rather than focus solely on potassium phosphate and mepivacaine.<\/p>\n

\u201cThere\u2019s a lot of things they\u2019re gonna have to fill in to get more safety for not just those two drugs, all of them, all of the high-risk meds,\u201d Skaer said.<\/p>\n

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 possible problem.<\/p>\n

Ascension said in response to the state report that it takes the findings \u201cextremely seriously\u201d and is continuing to cooperate with state and federal surveyors.<\/p>\n

The hospital says it self-reported the medication error to regulators and implemented changes to its pharmacy processes and safety protocols.<\/p>\n","protected":false},"excerpt":{"rendered":"An independent pharmacy expert says the medication error that harmed four patients at Ascension Saint Thomas Midtown was…\n","protected":false},"author":2,"featured_media":829880,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[58],"tags":[97,243],"class_list":["post-829879","post","type-post","status-publish","format-standard","has-post-thumbnail","category-medication","tag-health","tag-medication"],"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/829879","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/comments?post=829879"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/posts\/829879\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media\/829880"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/media?parent=829879"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/categories?post=829879"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/us\/wp-json\/wp\/v2\/tags?post=829879"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}