Mepivacaine

They set up their sterile tray.

They have their own vials, which they draw up at the bedside.

As the nurse, we do the timeout.

We make sure they're on the monitor.

So they're grabbing pre-drawn up medication.

Well, so here was what I was going to say is sometimes – For instance, and mainly when I've seen this, it's been in codes or whatever, right? Physicians will look at you and say, I want you to draw up rock and atomidate, right? So the nurses will then draw it up or whoever is handling the medications will draw up those two different medications that come in two separate different syringes, and we're kind of on standby with them.

But in order for us to not get them mixed up, whether we're in a shuffle of anything because the vials have already normally been put on the podium of the person that's going to be charting so that they can scan them, all of that stuff, we will label them and put ROC.

and like normally an abbreviation of atomidate on them that is what i'm wondering if that happened in this case like were they pre-labeled did we grab the wrong one with the wrong label on it or did these syringes come mislabeled pre-drawn up from pharmacy

The following day, four patients undergoing orthopedic surgeries were given the wrong medication in their spinal injections.

The medication they were supposed to receive was Mepivacaine, which is like a Novocaine or Lidocaine, something that you guys might know, which is an anesthetic.

Instead, they were given potassium phosphate, which is a medication that can cause serious and potentially life-threatening complications when administered incorrectly.

According to a state investigation, the four patients experienced severe reactions.

You could have to draw it up yourself and do it.

I'm like, oh.

So, the problem began when the pharmacy tech went to retrieve Mepivacaine.

The vials of Mepivacaine and potassium phosphate look very, very similar.

Knee replacements, yeah.

And they were supposed to have Mepivacaine, 2%, and they were given potassium phosphate.

which, yeah, obviously is a terrible error to four patients.

And I didn't know because I've been in a million C-sections.

We need systems, we need processes to be able to help to minimize those with checks and balances.

But at the same time, when a mistake does happen, we need to look at the root cause, do a root cause analysis, as Randy said, and figure out, was it production pressure? Was it a systems issue? Was it the fact that the medicines looked alike, sounded alike, spelled alike? It's Polocaine, is what I was trying to think of earlier.

It's another name from epiphany.

And I believe the label of that, yeah, I believe it was labeled right next to the potassium and polycaine.

Actually, let's go here.

So four patients at Ascension St. Thomas Hospital Midtown in Nashville were given potassium phosphate instead of the spinal anesthetic Mepivacaine during routine joint replacement surgeries on August 14th, 2026. and at least two have been left paralyzed.

And you may be wondering how, because of how the medication was given.

The hospital has confirmed the mix-up began as a pharmacy error.