By SCM Health Desk I Saturday, August 21,2026
NASHVILLE — What should have been routine, outpatient joint replacement surgeries at a prominent Nashville hospital degenerated into catastrophic medical emergencies when staff mistakenly injected concentrated potassium chloride directly into patients’ spines.
The severe medication mix-up occurred on Aug. 14 at Ascension Saint Thomas Hospital Midtown. Four patients undergoing routine joint operations were inadvertently administered spinal injections of potassium chloride—a high-alert chemical compound commonly used to treat severe electrolyte deficiencies but deadly when misadministered—instead of local anesthetic or epidural pain medication.
Operating room staff first realized a critical error had occurred when multiple patients rapidly suffered severe neurological symptoms and sudden cardiac arrest while on the table.
Among the victims is Glenda Dorton, 72, who entered the facility for a routine knee replacement. According to her family, Dorton woke up after surgery unable to feel or move anything from her chest down.
She was urgently transferred to an intensive care unit to have her spinal fluid drained and was placed on a mechanical ventilator. Family members reported that at least two of the four affected patients have been left paralyzed.
In a public statement, Dr. Shubhada Jagasia, president and chief executive of Ascension Saint Thomas Hospital Midtown, acknowledged the disaster and extended an apology.
”Our hearts are with the four patients and their families impacted by this event,” Dr. Jagasia said. “On behalf of our leadership and care teams, I am deeply sorry for the harm caused to our patients. We self-reported to state regulators and launched a thorough investigation. We identified the cause and have implemented corrective safeguards.”
The hospital has declined to release specific details regarding the clinical status of the remaining patients or the exact breakdown in protocol that allowed the wrong drug to reach the operating theater. Preliminary reports from victims’ families indicate the mix-up originated in the hospital’s pharmacy prior to the drugs being delivered to surgical suites.
The Tennessee Bureau of Investigation and the Tennessee Healthcare Facilities Commission have launched formal investigations into the facility.
Potassium chloride is designated as a “high-alert medication” by the Institute for Safe Medication Practices (ISMP), meaning it carries an exceptionally high risk of causing severe patient harm or death when administered incorrectly.
While potassium is an essential electrolyte for human physiological function, its concentrated intravenous or spinal delivery presents extreme biological dangers:
Spinal Toxicity: When injected into the intrathecal or epidural space of the spine, concentrated potassium destroys delicate nerve tissues. The chemical causes acute nerve inflammation, severe chemical burning, rapid spinal cord injury, and permanent paralysis.
Cardiac Arrest: Rapid introduction of excess potassium into the bloodstream alters the heart’s electrical impulses. This can instantly trigger fatal arrhythmias or cardiac standstill—the exact mechanism that makes potassium chloride a primary component in lethal injection protocols.
Historically, clear-vial mix-ups between potassium chloride and standard nerve-blocking agents (such as bupivacaine or saline flushes) have prompted strict hospital protocols. Federal standards typically require concentrated potassium to be sequestered in dedicated pharmacy areas and verified with dual barcode scanning before reaching a patient.
Investigators are currently examining electronic audit logs, pharmacy distribution chains, and surgical verification procedures to determine how multiple safety checks failed simultaneously in Nashville.
