Ascension Saint Thomas Midtown Update

Update as of September 9

Recent news coverage regarding Ascension Saint Thomas Midtown and West has generated understandable concern across the communities we serve. Ascension Saint Thomas Hospital Midtown and West are vital to this community and will remain open and operational.

Our heritage in Middle Tennessee spans more than 125 years, and our commitment to serving our community remains firm. We want to share the following facts regarding our operations, our regulatory work and our path forward:

• Our emergency departments, operating rooms, outpatient clinics, transfer centers and procedural areas are open and delivering care. Our patient volume across both campuses reflects the continued trust doctors and patients place in our clinicians and care teams every day.
• We self-reported the medication error that occurred last month and acknowledged our mistakes directly to the impacted patients and their families. We have implemented rigorous clinical safeguards and updated protocols across our pharmacy and surgical services - patient safety remains our highest priority.
• We are actively engaged in ongoing, structured collaboration with state and federal regulatory agencies. Administrative notifications and review cycles are standard components of the oversight process following a significant event. We are refining our corrective action plans in full coordination with these agencies to ensure every requirement is met.

Ascension Saint Thomas provides vital tertiary, medical, surgical, cardiovascular and maternal services that Middle Tennesseans rely on every day. Midtown and West are indispensable hospitals serving our community, and we remain fully dedicated to preserving access to high-quality care across Middle Tennessee.

Update as of August 27

Ascension Saint Thomas has received the survey report from Centers for Medicare and Medicaid Services (CMS) stemming from the recent event in the pharmacy at Ascension Saint Thomas Midtown. We have seen some inaccurate interpretations of this report in the media. For clarification, there were seven patients on the joint replacement surgical schedule on August 14. As we previously shared, four of those patients received the incorrect medication. Our support for those patients and their families remains unwavering.

Providing safe, high-quality, patient-centered care is at the core of our mission, and any gap in meeting that standard receives our immediate, uncompromising attention. Upon identifying the medication error on August 14, hospital leadership self-reported the event to regulators and implemented several changes to our pharmacy processes and safety protocols. We take the survey findings extremely seriously and are continuing to cooperate with state and federal surveyors to ensure a safe environment for our patients. We remain committed to upholding safety standards for every person who trusts us with their care.

Update as of August 21

Our hearts remain entirely with the four patients and families impacted by the recent event at Ascension Saint Thomas Hospital Midtown. On behalf of our leadership and care teams, 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.

To provide additional information regarding this event, on Friday, August 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. The four patients experienced adverse health reactions and received immediate medical care. A comprehensive review confirmed that no other patients were affected.

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.

Specifically, Midtown has implemented additional physical, technological, and clinical safeguards. The following changes are designed to address medication risks and uphold the standards of safety for our patients and teams:

• Isolated Medication Storage: High-alert medications, including mepivacaine, are stored in separate, distinctly marked locations to eliminate selection errors.
• Mandatory Hard-Stop & Escalation: Implement process to stop and resolve, through independent verification, for any spinal medication scan alert.
• Independent Dual Verification: Spinal medicine workflows now require a second trained pharmacist to perform final visual and physical checks.

Following our self-report, Ascension Saint Thomas continues to collaborate with state and federal officials to ensure a safe environment for our patients. Additionally, we have engaged independent, third-party quality experts to review and validate our mitigation plans.

Providing safe, high-quality, patient-centered care is at the core of our mission. Any gap in meeting that standard receives our immediate, uncompromising attention. We remain steadfastly committed to supporting those affected and upholding safety standards for every person who trusts us with their care.

Frequently Asked Questions

What happened?

On Friday, August 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.

When was this discovered?

The error was identified on Friday, August 14, and immediately self-reported to state regulators.

Did this impact any other patients?

Four joint replacement patients at the Midtown campus were impacted. A comprehensive review confirmed that no other patients were affected.

Did this impact any other service lines?

This was an isolated medication error limited to four joint replacement patients at our Midtown campus.

Was this reported to regulators?

Yes. Upon identifying the error on August 14, hospital leadership self-reported the event to state regulators. Ascension Saint Thomas continues to collaborate with state and federal officials to ensure a safe environment for our patients.

What steps have been taken to prevent this from happening again?

Midtown has implemented additional physical, technological, and clinical safeguards, including:

• Isolated Medication Storage: High-alert medications, including mepivacaine, are stored in separate, distinctly marked locations to eliminate selection errors.
• Mandatory Hard-Stop & Escalation: A process has been implemented to stop and resolve, through independent verification, any spinal medication scan alert.
• Independent Dual Verification: Spinal medicine workflows now require a second trained pharmacist to perform final visual and physical checks.

Additional corrective plans have been submitted for CMS approval.

How are you supporting the impacted patients?

Our teams continue to support these four individuals. We are also offering our support and spiritual care resources to their loved ones.