A state investigation into a drug mix-up at a hospital pharmacy has found multiple and systemic failures. The incident occurred two weeks ago and involved four patients receiving the wrong medication injected into their spines, resulting in horrific complications.

An expert brought in during the investigation noted that one failure after another by pharmacy employees, along with multiple systemic failures, led to the tragedy. A report detailing the findings has been released by the Tennessee Health Facilities Commission.

The 80-page report provides insight into what went wrong, but for further details, readers can refer to the full report. The investigation sheds light on the events surrounding the incident, which occurred on August 14th.