When a Medication Error Changes a Life
Patient Safety • Medication Safety • Nursing Practice
What healthcare professionals can learn from the reported bupivacaine–potassium mix-up at a Nashville hospital
Central Valley Medical Education • Educational Commentary • Updated August 20, 2026
Why we are talking about this: This article was prompted by a serious medication event recently reported at Ascension Saint Thomas Hospital Midtown in Nashville. NewsChannel 5 Investigates reported that syringes intended to contain the local anesthetic bupivacaine for joint-replacement patients were instead reportedly filled with potassium. Four patients were affected. The detailed root-cause findings have not yet been publicly released.
THE STORY THAT PROMPTED THIS DISCUSSION
What Happened in Nashville?
According to NewsChannel 5 Investigates, at least four patients were undergoing joint-replacement procedures at Ascension Saint Thomas Hospital Midtown when a medication mix-up occurred. The hospital later acknowledged that four patients had been affected, apologized for the harm, reported the event to state regulators, and said it had identified a cause and implemented corrective safeguards.
NewsChannel 5 reported that the syringes involved were supposed to contain bupivacaine, a local anesthetic used for regional or neuraxial anesthesia and analgesia, but were reportedly filled with potassium instead. The station reported that this information came from people familiar with the event; Ascension has not publicly released a detailed root-cause report explaining exactly how the medication substitution occurred.
The family of one patient, 72-year-old Glenda Dorton, told NewsChannel 5 that she had gone to the hospital for knee-replacement surgery and was supposed to receive an epidural for pain control. Her family reported that the wrong medication was injected and that she became paralyzed from the chest down and required intensive care.
On August 20, NewsChannel 5 further reported that the Tennessee Bureau of Investigation had opened an active investigation and that the Tennessee Health Facilities Commission was also reviewing the event. Those investigations are important because many details that healthcare professionals naturally want to know have not yet been publicly established. Read the NewsChannel 5 follow-up report.
✓ What is publicly supportedFour patients were affected. Ascension apologized, notified regulators, said it launched an investigation, said it identified a cause, and said corrective safeguards were implemented. NewsChannel 5 has reported that bupivacaine intended for the procedures was replaced by potassium in the syringes. |
! What has not been publicly establishedThe complete root cause, exactly how the wrong medication entered the syringes, who prepared them, who checked them, which safety barriers failed, and which individual professionals performed each step. |
This article is not an accusation. We are not claiming that a CRNA, RN, pharmacist, physician, pharmacy technician, or any other individual caused this event. We are discussing the event because a catastrophic medication mix-up was reported, and healthcare professionals need to understand how medication systems are supposed to prevent an error from reaching a patient.
The question is not only, “Who touched the syringe?” The deeper patient-safety question is, “How could the wrong drug move through enough steps and safeguards to reach a patient?”
WHY THIS MIX-UP IS SO SERIOUS
Bupivacaine and Potassium Are Not Interchangeable
Bupivacaine is a local anesthetic used for regional and neuraxial anesthesia and pain control. Potassium chloride is an electrolyte medication with very different indications, concentrations, routes, and hazards. Published medical literature documents that accidental neuraxial administration of potassium chloride can cause severe neurologic and cardiopulmonary injury, including paralysis, respiratory compromise, cardiac effects, permanent injury, and death.
That is why a reported substitution of potassium for a neuraxial anesthetic deserves close examination. The clinical consequences can be devastating, and a safe medication-use system should contain multiple opportunities to detect the wrong product before administration.
A catastrophic medication event is rarely prevented by one person “being careful.” It is prevented by layers of defenses.
SYSTEMS THINKING
A Medication Error Is Rarely Just One Decision
A medication may pass through prescribing, pharmacy verification, preparation, compounding, labeling, dispensing, storage, transport, retrieval, verification, administration, and patient monitoring. AHRQ patient-safety literature emphasizes a systems approach because errors can emerge from interactions among people, processes, technology, workload, environment, and organizational design.
Ascension Saint Thomas Midtown describes its own pharmacy services as including order verification, IV-room oversight and product checking, IV compounding, distribution, pharmacist review, and continuous quality improvement related to medication events. Those are exactly the kinds of system layers investigators will likely need to examine when determining what happened in this case.
- What was ordered for each patient?
- Where and by whom were the syringes prepared?
- What source container was used?
- How were the syringes labeled?
- Was there an independent product check?
- Were potassium products segregated from anesthetic products?
- Was barcode or machine-readable verification available?
- Did the product, concentration, label, or route create a warning?
- Were any warnings or mismatches overridden?
- Did workload, interruption, staffing, equipment design, or production pressure contribute?
- Was there a final verification before the medication left the pharmacy?
- Was there another verification before administration?
- Did more than one patient receive medication from the same preparation batch or workflow?
We do not currently know the answers to those questions. That is precisely why they are appropriate questions for a root-cause investigation rather than conclusions for social media.
SAFETY BARRIERS
What Should Have a Chance to Catch a Wrong Drug?
The Institute for Safe Medication Practices recommends multiple safeguards in perioperative and procedural settings. Its guidance includes standardized concentrations, complete syringe labeling, machine-readable codes on syringe and infusion labels where appropriate, immediate labeling when medications are transferred to another container, and visual and verbal medication verification when medications enter a sterile field.
These safeguards matter because the person administering a medication may not be the person who selected the original vial, compounded the medication, filled the syringe, printed the label, or transported the product.
That is exactly why the Nashville report matters as a teaching case. If a syringe intended to contain bupivacaine reportedly contained potassium instead, the safety question is not limited to the final moment of administration. Investigators need to trace the medication through every earlier step where the wrong product could have been selected, prepared, labeled, checked, transported, accepted, or detected.
| Pharmacy controls Product selection, compounding process, labeling, independent checking, storage, segregation, and final product verification. |
Technology controls Barcode or machine-readable verification, automated dispensing safeguards, electronic medication records, alerts, and route-specific workflow controls. |
| Clinician controls Medication, concentration, route, order, label, patient, indication, and clinical-reasonableness checks before administration. |
Organizational controls Staffing, competency, training, supervision, reporting culture, policies, auditing, and rapid response when a safety barrier fails. |
HUMAN FACTORS
Excellent Clinicians Can Still Make Errors
Healthcare professionals are human. Fatigue, interruptions, confirmation bias, look-alike products, assumptions about earlier checks, alert fatigue, time pressure, and normalized workarounds can weaken safety.
The answer cannot simply be: “Be more careful next time.”
A workaround may reflect unsafe conduct, but it can also reveal a badly designed process, equipment failure, excessive alerts, supply problems, staffing problems, or a workflow that routinely makes compliance difficult. A proper investigation has to distinguish between those possibilities.
That distinction is particularly important here. NewsChannel 5 has reported that people familiar with hospital pharmacy operations believe multiple safety checks should exist, but the public still does not know exactly which barriers were present, which were followed, or where the process broke down.
CALIFORNIA PRACTICE
RN and CRNA Are Not Interchangeable Terms
The Nashville event occurred in Tennessee, so California healthcare professionals should not assume that Tennessee and California scope-of-practice rules are identical. They are not.
This distinction is especially important because the reported medication was intended for neuraxial anesthesia or analgesia. In California, the Board of Registered Nursing identifies the Certified Registered Nurse Anesthetist as an advanced-practice nurse with specific nurse-anesthesia authority. The BRN states that anesthesia services may be provided by a CRNA when requested by a physician and without a requirement for physician supervision or standardized procedures.
Why this still matters to every RN: Although an ordinary bedside RN would not independently practice nurse anesthesia simply by holding an RN license, California RNs remain accountable for the medications they administer. That includes knowing the medication, why it is being given, the ordered dose and route, expected effects, potential complications, required monitoring, and when something is unsafe enough to stop and clarify. A medication does not become safe merely because another professional ordered, prepared, labeled, or dispensed it.
California RNMay administer appropriately ordered medications and therapeutic agents within nursing scope, competency, applicable law, professional standards, and facility policy. |
California CRNAIs an advanced-practice nurse with specialized education and certification and a separate statutory framework for anesthesia services. |
Important: Current public reporting does not establish which professional prepared, checked, transported, selected, or administered each medication in the Nashville event. This article therefore does not attribute the event to “the CRNA,” “the nurse,” “the pharmacist,” or any other individual.
THE STOP MOMENT
What Happens When Something Does Not Look Right?
STOP
Suppose the barcode will not scan. The medication does not match the order. The concentration looks unfamiliar. The vial or syringe looks different. The route seems wrong. The product came from somewhere else and you did not prepare it. Or something simply does not fit the clinical picture.
The warning may be a technology problem. It may be harmless. It may be explainable. But it may also be the final barrier between an upstream mistake and the patient.
“Something doesn’t look right. I’m going to stop and verify it.”
That is not weakness. It is professional discipline.
JUST CULTURE
Learning From an Event Does Not Mean Eliminating Accountability
A learning culture should not begin by searching for someone to punish. It also should not ignore dangerous conduct. Patient-safety analysis should distinguish among human error, system defects, risky workarounds, competency problems, and deliberate disregard of known safety requirements.
Those categories are not interchangeable. A professional who makes an unintended error within a defective system presents a different problem from someone who knowingly disregards a critical safety requirement. Evidence—not assumptions—should determine what occurred.
In a Just Culture framework, behavior is commonly examined as:
| Human Error An unintended action or mistake. Ask what system changes can make recurrence less likely. |
At-Risk Behavior A choice in which the risk may be underestimated or normalized. Ask why the behavior made sense in the real workflow and how safer choices can be reinforced. |
Reckless Behavior A conscious disregard of a substantial and unjustifiable risk. If the evidence supports this, individual accountability remains appropriate. |
Competency is still part of the investigation. It is not a separate Just Culture behavior category, but investigators should still evaluate education, training, demonstrated competency, supervision, role expectations, staffing, workflow, technology, labeling, storage, and other system conditions that could have contributed to the event.
TAKE IT BACK TO PRACTICE
What Should Healthcare Professionals Ask Before Giving a Medication?
The Nashville event is still under investigation, but the reported bupivacaine–potassium substitution gives every healthcare professional a reason to reexamine the final checks performed before a medication reaches a patient.
✓ Do I know exactly what this medication is?
✓ Do I know why this patient is receiving it?
✓ Does the dose and concentration make sense?
✓ Is this the correct route?
✓ Did I verify it against the actual order?
✓ Is the syringe or container properly labeled?
✓ Does the medication look different from what I expected?
✓ Am I relying on someone else’s assumption instead of performing my own required check?
✓ Did a safety system produce a warning or mismatch that I am about to bypass?
✓ If something seems wrong, am I willing to stop?
And perhaps the most important question:
“If I am wrong, what could happen to this patient?”
BOTTOM LINE
The Goal Is Not to Hide the Story. The Goal Is to Learn From It.
A reported medication mix-up in Nashville placed a serious patient-safety issue in front of the healthcare community: syringes intended to contain bupivacaine were reportedly filled with potassium, four patients were harmed, and multiple investigations are now underway.
We should talk about that plainly.
We should also be disciplined enough not to invent the parts we do not yet know.
The patients deserve answers. Their families deserve transparency. The healthcare professionals involved deserve a fair investigation based on evidence. And every healthcare organization should ask whether its own systems could detect a similar wrong-drug error before it reached a patient.
The order matters.
The source vial matters.
The pharmacy process matters.
The label matters.
The concentration matters.
The route matters.
The barcode matters.
The independent check matters.
The clinician who stops matters.
The colleague who listens matters.
And the organization willing to examine its own system matters.
The source vial matters.
The pharmacy process matters.
The label matters.
The concentration matters.
The route matters.
The barcode matters.
The independent check matters.
The clinician who stops matters.
The colleague who listens matters.
And the organization willing to examine its own system matters.
Patient safety is not about pretending healthcare professionals never make mistakes.
It is about building enough reliable defenses that one mistake does not automatically become a patient’s catastrophe.
Sources & Further Reading
- NewsChannel 5 Investigates — Drug mix-up during surgeries at Ascension Saint Thomas Midtown.
- NewsChannel 5 Investigates — TBI investigating the Nashville medication mix-up.
- Ascension Saint Thomas Hospital Midtown — Pharmacy Department and practice model.
- AHRQ PSNet — Systems Approach to Patient Safety.
- AHRQ PSNet — Accountability in Patient Safety.
- Institute for Safe Medication Practices — Guidelines for Safe Medication Use in Perioperative and Procedural Settings.
- PubMed — Narrative review of accidental neuraxial potassium chloride administration.
- PubMed — Case report of accidental epidural potassium infusion.
- California Board of Registered Nursing — Certified Registered Nurse Anesthetist.
- California Board of Registered Nursing — Nursing Practice Act.
- California BRN — Conscious/Moderate Sedation Guidance.
- Tennessee Department of Health — Board of Nursing.
Educational Disclaimer: This article is intended for healthcare education and patient-safety discussion. It is not legal advice and does not determine liability, negligence, criminal responsibility, or professional misconduct in the Ascension Saint Thomas Hospital Midtown event. The Tennessee Bureau of Investigation and state regulatory review are ongoing, and publicly reported facts may change as additional information becomes available. Healthcare professionals should follow current law, licensing-board requirements, individual scope and competency, valid orders, applicable institutional policies and procedures, and current professional standards.
Central Valley Medical Education
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Building safer, more confident healthcare professionals through education.