A medication error at a Nashville hospital that left four patients critically ill after routine joint-replacement surgeries is raising fresh questions about patient safety.
A former nurse who worked at the facility says she saw troubling warning signs well before the incident occurred.
Brenda Cleghorn spent nearly 10 years working at Ascension Saint Thomas Midtown before resigning in June—just two months before four joint-replacement patients were mistakenly given potassium phosphate rather than the local anesthetic mepivacaine.
Her allegations come as state and federal regulators document significant safety failures at Ascension Saint Thomas.
UPDATE: In August, 4 patients at Ascension St Thomas Midtown Nashville hospital were getting joint replacements. They given the wrong drug by the pharmacy with catastrophic consequences.
A former nurse is speaking out. pic.twitter.com/w3nMyORwkP— Booker (@RealBookerScott) September 19, 2026
Cleghorn told NewsChannel 5 Investigates that repeated concerns over patient safety were a major reason she decided to leave. Before resigning, she recalled warning colleagues, “Something bad is going to happen.” She said she never imagined the consequences would be catastrophic.
As RedState previously reported, the four patients received potassium phosphate after the medication was mistakenly labeled as mepivacaine. The error led to devastating medical consequences.
State investigators said all four patients required transfer to facilities capable of providing a higher level of care. At the time investigators completed their exit review on Aug. 21, one patient remained dependent on ECMO life support. The other three were experiencing severe neurological damage affecting their lower bodies, including paralysis and loss of sensation.
Regulators also uncovered a series of failures that occurred before the incorrect medication ever reached the operating room.
According to surveillance footage reviewed by investigators, a pharmacy technician selected potassium phosphate while assembling an order for mepivacaine. The two medications were packaged in similar-looking vials. When the potassium phosphate failed to scan, the technician bypassed the barcode system using an override.
A second technician later filled syringes from the vial and labeled them as mepivacaine without independently confirming the medication. That technician told investigators checking the vial had not been standard practice.
The pharmacist’s final review also failed to identify the substitution. Investigators said the verification process lasted roughly 29 seconds.
Cleghorn said the circumstances resembled medication problems she had encountered while working at Midtown. In one instance, she scanned a patient’s medication and discovered it had been stored in the wrong location.
“It wasn’t even the right medication,” she told NewsChannel 5.
She offered another troubling account, saying that during her three weekly night shifts, she could almost count on receiving medication at least once that did not match the label on the bag.
Cleghorn said she completed the required incident reports after discovering those errors, but often received little or no follow-up and continued to encounter medication-related concerns. She also pointed to what she described as broader problems involving staffing and employee training.
“I had nurses that didn’t know how to hang IV fluids,” Cleghorn said. “They had no idea how to give antibiotics.”
She also said nurses were sometimes left “guessing” their way through peritoneal dialysis and alleged that the hospital’s stroke unit at times operated without a nurse certified in stroke care. Cleghorn said conditions deteriorated to the point that she feared for her own nursing license whenever she reported for duty.
State investigators determined that the Aug. 14 medication error resulted from breakdowns at several stages, including drug selection, barcode scanning, syringe preparation and the pharmacist’s final verification.
In a more recent finding, investigators said hospital leadership had “failed to ensure medication errors and adverse patient events were promptly investigated and analyzed.” Officials also said the hospital did not ensure that corrective and preventive actions were put in place.
That makes her account especially compelling. She says she personally encountered incorrectly labeled or misplaced medications, repeatedly filed reports about safety problems and ultimately left because she believed “something bad” was going to happen.
Ascension disputes Cleghorn’s broader characterization of the hospital.
“We take concerns raised by our team members seriously,” the hospital told NewsChannel 5, saying safety reports trigger internal reviews and corrective action.
There has also been an important regulatory development since the original disaster.
Federal regulators removed Ascension Saint Thomas Midtown and West from “Immediate Jeopardy” status on Sept. 16 after corrective measures were put in place, meaning the hospitals were no longer in immediate danger of losing Medicare participation.
But that doesn’t erase what investigators found or answer what Cleghorn is alleging happened before four patients were catastrophically injured.
Ascension says it has introduced additional safeguards, including separated storage for high-alert medications, mandatory escalation when certain medication scans trigger alerts and independent verification by a second trained pharmacist.
The safeguards may help prevent another disaster. But if her account is accurate, this wasn’t simply an unforeseeable mistake that came out of nowhere.
She says she saw repeated medication problems, reported them and warned that “something bad” was going to happen. Then something “inevitably” did.
This makes it harder for Americans to trust that our “watchdog” institutions are giving us the straight story about what is going on throughout the medical industry.
After what the country witnessed during the pandemic, it’s hard to blame them.
Editor’s Note: The mainstream media continues to gaslight, spin, and lie about President Trump, his administration, and conservatives.
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