The Tennessee Bureau of Investigation has opened its own investigation into the medication error at a Nashville hospital that left four surgery patients seriously harmed, including one paralyzed, on Aug. 14.
A bureau spokesperson confirmed to The Epoch Times that the investigation into the incident at Ascension St. Thomas Midtown Hospital in Nashville is active and ongoing.
The possibility of criminal charges comes on top of an ongoing administrative inquiry by the Tennessee Health Facilities Commission, which has rejected the hospital’s initial corrective action plans after a five-day onsite investigation.
The facility self-reported the error the day it happened, according to a hospital statement.
The joint-replacement patients were given potassium phosphate, normally used to treat low levels of blood phosphorus, instead of the spinal anesthetic Mepivacaine when undergoing joint replacements.
All four patients experienced neurological systems, trouble breathing, and poor circulation. The most severely affected patient was paralyzed below the midsection.
What Happened
According to a Health Facilities Commission report, a cascade of errors led to four of seven surgery patients receiving the wrong drug.
Starting on Aug. 13, the day before the surgeries, video surveillance showed hospital employees preparing the medication for the following day, the report said.
One employee retrieved the wrong medication from supply bins. A second drew the medication into syringes. And a third signed off on the preparation and set the drug out for use the following day, as documented in the commission’s report.
All that despite a series of safety checks detailed in the report—including some that were overridden—that should have ensured that the mistake was caught.
The report specifically noted that an employee was able to override the computer system when it rejected the barcode scan of a drug vial and manually enter information without oversight by a pharmacist.
The next day, after the wrong drug was administered, the clinical staff didn’t respond quickly enough, according to the report, and all four patients showed worsened neurological responses, breathing, and circulation.
“Our hearts remain entirely with the four patients and families impacted by the recent event at Ascension Saint Thomas Hospital Midtown,” the hospital said in an Aug. 21 statement.
“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,” the statement added.
Immediate Jeopardy
The Health Facilities Commission made an unannounced site visit at the hospital starting Aug. 16. The purpose was to determine the hospital’s compliance with Medicare regulations.
The commission identified three “immediate jeopardies.” That’s a Medicare term meaning that the provider has caused or is likely to cause serious harm or death to a patient.
The hospital called the incident an isolated medication error, and said it had instituted additional safeguards, according to a statement.
But the commission rejected three action plans submitted by the hospital, saying they didn’t do enough to correct the conditions that led to patients being harmed. When the site visit ended on Aug. 21, the three immediate jeopardies remained in place, the report said.
During the site visit, the commission expanded the investigation to include Ascension St. Thomas West, the sister facility to St. Thomas Midtown because the two operate as one and share a Medicare ID.
“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,” the hospital stated on Aug. 31.
Logan Grant, executive director of the Health Facilities Commission, declined to comment on the status of the inquiry but told The Epoch Times the commission is working with the Centers for Medicare and Medicaid Services to protect patients.
The Centers for Medicare and Medicaid Services did not respond to a request for comment by the time of publication.
Reaction
The American Pharmacists Association and Pharmacists Advancing Hospital Care issued a joint statement urging sympathy both for the victims of medication errors and those who have made them, who can experience grief and a lasting sense of responsibility.
“No pharmacist, physician, nurse, technician, or other healthcare professional comes to work intending to harm a patient,” the groups wrote in an Aug. 21 statement. “Our organizations also stand firmly against punitive actions that criminalize medication errors.”
Ascension St. Thomas Midtown Hospital is a 435-bed facility that conducts about 10,700 surgeries each year, according to the American Medical Association.
The hospital operates in tandem with Ascension St. Thomas West, a 428-bed campus that performs about 12,000 surgeries a year.
The combined entity employs about 2,500 people and reported revenue of more than $1.2 billion in 2025.
Ascension is the fifth-largest hospital system in the United States, owning outright or in part 119 hospitals in 16 states and the District of Columbia.
The system employs nearly 100,000 people, including more than 5,000 physicians and 3,000 pharmacy professionals.
A spokesperson for Ascension St. Thomas Midtown referred a request for comment to previous statements and updates on the hospital website.
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