A 72-year-old Tennessee woman walked into a Nashville hospital for a knee replacement. Her family says she came out of the procedure unable to move or feel anything from her chest down.
Glenda Dorton was one of four patients affected by a medication mix-up at Ascension Saint Thomas Hospital Midtown on Aug. 14. According to her family, the anesthetic intended for her epidural was replaced with potassium chloride, a medication that can be extremely dangerous when administered incorrectly.
The hospital has acknowledged that four patients were harmed in what it has called an “event,” apologized to the families, and said it identified the cause and put new safeguards in place. It has not publicly explained exactly how the medication mix-up happened. NewsChannel 5 first reported the incident and has since learned that two of the four patients were left paralyzed.
Now, the investigation has expanded beyond the hospital and state health regulators. The Tennessee Bureau of Investigation has confirmed it is looking into what happened.
She Went In For A Knee Replacement
Dorton, an active gardener from Centerville, Tennessee, had reportedly put off knee replacement surgery because she did not want the downtime. On Aug. 14, she finally went to Ascension Saint Thomas Midtown for the procedure.
Her family says she was supposed to receive bupivacaine, a local anesthetic, through an epidural before surgery. Instead, they say potassium chloride was injected into her spine.
Dorton’s daughter-in-law, Kristina Dorton, told The Tennessean that the medication came directly from the hospital pharmacy, according to what the family was told. She was also careful about where the family believes responsibility lies.
“This was not the doctor’s fault,” she said. “This was not the anesthesiologist’s fault. This was not the care team’s fault.”
The family said Dorton’s knee replacement itself seemed to go well. The problem became clear when she woke up.
Something Was Wrong When She Woke Up
Dorton’s family told WSMV that she was itching, felt as though her body was burning, and could not feel her legs.
She was transferred to Ascension Saint Thomas Hospital West, where doctors placed her on a ventilator and drained spinal fluid in an effort to remove excess potassium, according to her family. She was also given high-dose steroids in hopes of reversing the damage.
The ventilator was removed the following day, but Dorton still could not move her lower body or feel anything from around her ribcage down.
On Aug. 18, her family said hospital staff told them she had T6-level paralysis, referring to the sixth thoracic vertebra in the middle of the back. Her family is still hoping doctors can determine whether any of the damage can be reversed.
Four Patients Were Affected
Dorton was not the only patient involved.
Ascension Saint Thomas Midtown has confirmed that four patients were affected. Dorton’s family told The Tennessean that hospital employees said three other joint-surgery patients were treated with what they described as “contaminated vials” before staff noticed similar complications in two patients and stopped surgeries.
NewsChannel 5 subsequently reported that at least two of the four patients were left paralyzed. The station also reported that a 74-year-old Nashville woman remained on a ventilator in intensive care and that a middle-aged man was critically ill. Those details come from families and hospital sources rather than a public accounting from Ascension, which has cited patient privacy in declining to disclose the other patients’ conditions.
Dr. Shubhada Jagasia, president and CEO of Ascension Saint Thomas Midtown, apologized to the patients and their families.
“Our hearts are with the four patients and their families impacted by this event,” Jagasia said in a statement.
She said hospital officials met directly with each family and connected them with resources and ongoing care. The hospital also said it reported the incident to state regulators on the day it occurred, launched an investigation, identified the cause, and implemented corrective safeguards.
Ascension has not publicly disclosed what it determined caused the mix-up or what specific safeguards were added.
Why Potassium Chloride Is So Dangerous
Potassium chloride itself is not an unusual medication. It can be given to patients for legitimate medical reasons, including treatment of low potassium levels.
How it is administered matters enormously.
Dr. Matthew Byrnes, a California surgeon who is not involved in Dorton’s treatment, told WSMV that potassium chloride has to be administered carefully and slowly. Giving too much or administering it incorrectly can cause serious cardiac problems and tissue damage.
Potassium chloride has also been used as one component of Tennessee’s lethal-injection protocol in the past, although Tennessee now uses a different execution drug. That does not mean its ordinary medical use is comparable to an execution. The danger in this case is the family’s claim that the medication was injected into Dorton’s spine rather than administered in its intended medical manner.
Byrnes said surgical medications can look nearly identical, making labeling and verification procedures particularly important.
“You have to look at the details closely and look at what you’re infusing before you put it in,” he said.
The Investigation Is Getting Bigger
The Tennessee Health Facilities Commission has received complaints and is investigating Ascension Saint Thomas Midtown. The Tennessee Bureau of Investigation has now opened an investigation of its own.
The TBI described its investigation to NewsChannel 5 as “active and ongoing.”
Exactly what investigators are examining has not been publicly detailed, and the existence of a TBI investigation does not by itself establish criminal wrongdoing.
Dorton’s family, meanwhile, has said it is speaking with an attorney. They have also struck a notably measured tone about what they want from the hospital.
Kristina Dorton told The Tennessean that the hospital had been transparent with the family and said they were grateful for that communication. She also said the family had no reason to believe a rogue employee intentionally caused what happened.
“We’re not looking to ruin somebody’s life,” she said. “They need to figure it out so it never happens.”
For Dorton and her family, the consequences are already much more immediate. A surgery she had delayed because she did not want to spend time recovering from a knee replacement has instead left her in intensive care, with her family waiting to learn how much of the damage, if any, can be reversed.