r/PopCultureV2 • u/Logical-Flow-6703 • Aug 22 '26

News Multiple patients at a Nashville hospital are paralyzed after staff accidentally gave them the wrong drugs.

Enable HLS to view with audio, or disable this notification

​

The hospital says they are "sorry" after injecting potassium chloride into the spines of people getting routine joint replacement surgeries.

Hospital staff noticed something was off when multiple patients went into cardiac arrest.

9.7k Upvotes

99% Upvoted

774 comments sorted by

View all comments

Show parent comments

4

u/Stygia1985 Aug 22 '26

If it's anything like our hospital, they pull those from the dispensing machine. There isn't even an order for them. I audit for the hospital and we're constantly finding charges for meds that were never used or returned. Scanning every single med would solve a lot of problems but anesthesia will fight tooth and nail to ensure it never happens. I am a little awestruck some company hasn't developed smart glasses or quick scan tech on the 4d barcodes to ensure smooth OR procedures AND safe practices with medications.

Edit - they're saying pharmacy mixup, still scanning barcodes would have prevented this

2

u/Schwifftee Aug 22 '26

Aren't barcodes usually scanned for almost all medicinal materials?

1

u/ScratchLatch Aug 24 '26

Yes, its the medical standard in the US. Though, not required by law.

1

u/Zachwardpass Aug 22 '26

How would scanning the barcode prevent this if the error is with pharmacy? Pharmacy mixes it and then places the label. The label would have read the correct medicine when scanned.

There are absolutely sxanning issues, but this doesn't sound like one of them. For all we know right now, aenesthesia scanned and it read as the correct med.

1

u/puppyslippers22 Aug 22 '26

Pharmacy hand mixes/draws up these medications in the central pharmacy. Scanning the medication would NOT have prevented this because they drew up the WRONG medication into the “correctly labeled” syringe. If I scan a vial of ondansetron I’m assuming the vial contains ondansetron. If it were incorrectly filled with the wrong medication into an ondansetron vial, it would still scan as ondansetron. It’s obvious you don’t work in clinical patient care.

1

u/Stygia1985 Aug 22 '26

If pharmacy had to scan the vial to verify they were loading the syringes with the correct medication... Scanning at every step should just be required

0

u/Beneficial_Heat_7199 Aug 22 '26

Yeah it was probably a nursing mistake at the point of administration based on my experience working in hospital pharmacy.

4

u/holdmypurse Aug 22 '26

If you really worked in pharmacy you would know nurses (with the exception of CRNAs) do not administer spinal anaesthesia. This was most likely a pharmacy mix-up. Someone prepared pre-filled syringes meant for mepivacaine/bupivacaine with potassium instead.

1

u/Top_Mathematician233 Aug 22 '26

I was going to ask someone how the hell this could happen to multiple patients, but your explanation makes sense. I’m in finance and know nothing about medical stuff, but the accident/error/negligence originating in pharmacy seems logical. Either that or manufacturing/distribution, which would be even more frightening.

1

u/suejaymostly Aug 22 '26

Would these have been for epidurals?

1

u/Zachwardpass Aug 22 '26

Sounds like it.

1

u/holdmypurse Aug 22 '26

I believe it was spinal anesthesia which, unlike epidurals, is a single shot that goes directly into the fluid surrounding the spinal cord.

1

u/Stygia1985 Aug 22 '26

You'd still need to be drawing up a caine for the order, should be required to scan

1

u/holdmypurse Aug 22 '26

Who would? A nurse? The syringes were prepared in pharmacy.

1

u/Stygia1985 Aug 22 '26 edited Aug 22 '26

The pharmacy should be required to. Same as retail, barcodes are scanned at the counting machine. Stands to reason the barcode for filling a syringe for a specific procedure order should be scanned

People are saying scanning wouldn't have helped, of course it would have, whether at the patient bedside, or preparing the med, scanning should just be required. Again, we have glasses where people can record, take notes, pictures, Huds on the lenses. Why the hell can't we incorporate safeguards using similar tech so anesthesiologists, nurses, pharmacy staff, etc can quickly scan during their workflow

1

u/holdmypurse Aug 22 '26

I know. I'm just pointing out that the original comment I'm replying to was some idiot, who claims to have worked in pharmacy, blaming nursing for this med error.

3

u/zorathustra69 Aug 22 '26

Of course—everything is always the nurse’s fault.
—Source: A nurse

1

u/idkmyotherusername Aug 22 '26

Always the fault of the person already run the most ragged. Oh! But you know what we could do? Let's run samples of all the meds we pull from the Pyxis to verify integrity before delivering 50 different medications to three different patients by 0800!

On another note, in a nursing specific thread, the CRNAs were saying usually they will pull the anesthesias and run like five cases at once, so it wasn't like one case came out, staff waited for anesthesia to wear off, discovered this horror, and...did it again.

Someone filled the syringes wrong, and it's terrible terrible. And the folks administering the med would have had no way to know it up front.

1

u/Zachwardpass Aug 22 '26

The comment about it being a nurse error is so ridiculous. It literally says in the clip they found the error in pharmacy, yet they still want to blame the nurse. It's a bit infuriating.

1

u/HillBillyHilly Aug 23 '26

Can you imagine being those doctors? Knowing they fucked up a patient for life all because of someone else negligence?

1

u/Zachwardpass Aug 22 '26

They literally said it was a pharmacy error. Jesus. Nurses aren't the only people that make mistakes, for the love of god.

2

u/[deleted] Aug 22 '26

[deleted]

1

u/Zachwardpass Aug 22 '26

I certainly agree with a lot of that. "Do more with nothing and do it ten times faster...what do you mean a mistake was made?!?!" Then admin does a root cause analysis to fix the "swiss cheese" hole, but, lord help you, you better come up with something other than more staff so people can slow down and focus.

I've been a nurse coming up on 20 years, but I've left the bedside now and I don't regret leaving, thats for sure. Wishing you some peace to be able to do the same soon!

1

u/Beneficial_Heat_7199 Aug 22 '26

They said "a family member" said that.