The Nashville Hospital Medication Mixup Explained by Nurses | The ER Edit Ep. 29

The Nashville Hospital Medication Mixup Explained by Nurses | The ER Edit Ep. 29

Four joint replacement patients in Nashville received potassium phosphate instead of the intended spinal anesthetic, mepivacaine, and the investigation shows just how many opportunities there were for someone or something to catch the mistake. We break down the pharmacy workflow and medication safety failures, then bring back some of the wildest medication error stories we have heard before ending with a truly chaotic round of Whisper Line submissions.

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The views and opinions expressed in this episode are those of Caitlin Armstrong and Karlie Tooley and do not represent the views, policies, or positions of their current or former employers, hospitals, healthcare organizations, or any affiliated institutions. This podcast is for entertainment and general discussion purposes only and should not be considered medical advice.

00:00 The Nashville Potassium Phosphate Mixup
01:02 How Spinal Anesthesia Usually Works
03:39 How Did the Wrong Syringes Get There?
05:30 Potassium Phosphate Reaches the Spine
06:36 Four Patients Are Seriously Harmed
08:47 Inside the 80 Page Investigation
09:04 How the Pharmacy Error Started
11:33 Five Syringes Get the Wrong Medication
13:45 The 29 Second Verification
15:38 Why We Want to See the Vial
16:01 What Happened After the Error
18:22 The Wild Medication Errors Begin
21:25 Tap Water in a Central Line
24:28 Medication Errors We Cannot Explain
27:41 The Whisper Line Gets Wild

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