how automated healthcare fails, how you'd know, and what to do at each tier — every claim sourced, reviewed continuously
On 14 August 2026 four joint-replacement patients at Ascension Saint Thomas Midtown received potassium phosphate instead of the anaesthetic mepivacaine. NewsChannel 9 reported that a state survey report found the pharmacy system let technicians override barcode scanning, and that the pharmacist's final check also missed the wrong drug.
TierThe pharmacy systems stayed up; according to the state report as described by NewsChannel 9, the barcode check could be overridden with manual entry, which is automation bypassed. How tiers are assigned.
Ascension Saint Thomas said that on 14 August 2026 four joint-replacement patients at its Midtown campus 'mistakenly received potassium phosphate, instead of the intended anesthetic medication, mepivacaine'. It said leadership self-reported the event to state regulators that day. Citing affiliate WTVF, CBS News reported that the operations were meant to be outpatient procedures. It also reported that the state's healthcare facilities commission alerted the Tennessee Bureau of Investigation, which was investigating. NewsChannel 9 reported on an 80-page Tennessee Health Facilities Commission report, shared with CMS, from a survey completed on 21 August. As NewsChannel 9 describes the report, surveillance video showed a pharmacy technician preparing syringes with potassium phosphate and labelling them as mepivacaine. The report found that the pharmacy system let technicians override barcode scanning and enter medication information manually, and that the pharmacist's final verification did not catch the wrong drug. It also cited a technician with documented training concerns and problems with peer review and staff training, and it placed three areas under 'Immediate Jeopardy'. Ascension said it now stores high-alert medications separately and requires any spinal-medication scan alert to be stopped and resolved through independent verification. A second trained pharmacist now does the final check on spinal medicines. Ascension said CMS removed the Immediate Jeopardy status on 16 September 2026. It also stated: 'We have seen some inaccurate interpretations of this report in the media.'[1,2,3]
Ascension says the four patients had adverse reactions and received immediate care. NewsChannel 9 says the state report describes worsening neurological, breathing and blood-pressure problems. CBS News reported families telling WTVF that two patients were left paralysed and one was in intensive care.
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