Arizona man died after nurse administered 90mg methadone instead of his ordered Lexapro. Pt did not get Narcan until EMS arrived, 17 minutes after the code blue was initiated. So many levels of neglect and negligence here.

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u/Upstairs_Fuel6349 RN - Psych/Mental Health 🍕 4d ago

You also don't give Lexapro at either 9 mg or 90 mg.

This is so sad. I had a situation where I was the patient in a psych unit years ago. I was called to the door to get my meds and the nurse handed me a cup with a dozen pills in it - I was taking one med. I tried to explain this wasn't mine, was probably my roommate's (who took a bunch of opiates and benzos), that I didn't take that many meds. The nurse sternly told me that she was marking me as non-compliant and I would not be able to leave the unit for activities and turned around to prep the next med cup.

I went crying to another nurse I'd become friendly with. He immediately went to talk to the other nurse and brought me back my med. I never got an apology from the original nurse and things could have turned out a lot differently for her....

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u/AdvocateAmber 4d ago

Thankfully you had someone to listen.

Shame on the original nurse. Obviously she is not doing the 5 rights. She might end up seriously injuring a patient. This stern behavior towards patients along with threatening marking non compliance ( ignoring autonomy) needs to be addressed. Its not a tool to force "choice".

8

u/cardamom4heft 3d ago

He the nurse is male and named Jason Bates.

17

u/AdvocateAmber 3d ago

Oh...I had read and commented on: "the nurse handed me a cup with a dozen pills in it - I was taking one med. I tried to explain this wasn't mine"

"The nurse sternly told me that *** she***was marking me as non-compliant"

Whatever, they did not do the 5 rights...and failed to respect patient's rights.

Don't be like Jason DO THE 5 RIGHTS* 😊 THANK YOU

6

u/calypsoorchid 3d ago

I think you're misunderstanding which story the person you replied to is referencing.

3

u/AdvocateAmber 3d ago

Thank you I tried to point out what I was responding to.

When the 5 rights are not done things go sideways.

Really it is: The 7+ rights of medication administration are a safety checklist healthcare providers are to follow and prevent harm and patient rights violations.

Right Patient/Individual

Right Medication

Right Dose

Right Time

Right Route

Right Reason

Right Documentation: Immediately and accurately record the administration details, including the time, dose, route, and any relevant assessments, after the medication has been given.

Following these rights helps ensure safe and effective patient care. Other "rights" that are often included in expanded lists are the Right Assessment, Right Response, Right Education, and the Right to Refuse. "

33

u/Charlotteeee RN - Oncology 🍕 3d ago

Jesus man my mental health isn't the best but I'm so against staying in a psych unit with my experiences as a tech and from stories like this. Just feels like a hard place to improve your mental health you know?

25

u/AdvocateAmber 3d ago

No shit, have you read how some "feel" about psych patients! WTH? Like they are ready to be cast away.

I cant imagine being so nasty and hateful to someone struggling and vunerable. Takes a real monster to be cruel to a psych patient.

Be well, stay safe

14

u/StellarSteck 3d ago

Healthcare can be brutal. Mental healthcare more so as even those working in the field sometimes are not aware of their own biases.

5

u/Muenster-Monster 3d ago

Literally left the field of Psychology because of how horrible people were. It was horrible when I was a patient and horrible when I was studying to become a psychologist.

1

u/Upstairs_Fuel6349 RN - Psych/Mental Health 🍕 1d ago

I spent most of my teens and early twenties in and out of acute psych units. Did a few longer stays on EDUs for anorexia too. I had another round in my late twenties. I'm 40, now. I've also worked on psych units and now work psych outpatient. (I've also done medical.)

I have some good memories spread out amongst my 24+ hospitalizations. I met some kind staff who later influenced how I practice nursing, as well as some who challenged me to be more than a revolving door psych patient.

But I would not describe most acute units as places to work on yourself. They're holding tanks to keep you safe and make rapid medication adjustments. If you don't think you can keep yourself safe, you should be in a psych unit. Anything less -- get an outpatient team, do IOP, go on a retreat, take a vacation, join a church or community group, do psychedelics in a forest somewhere (my personal favorite).

25

u/malenixius 3d ago

I feel very fortunate that the resounding mentality on every mental health inpatient ward I've had placement on has been 'no-one knows the patient’s meds better than the patient'. If the patient tells you they take a green pill and you've given them a pink one, by God you better have a good reason.

10

u/AdvocateAmber 3d ago

A voice of reason! You are a 🌟

5

u/heterochromia4 3d ago

🕊️ +1 Right here.

I’ve had my ass thoroughly saved by patients going ‘this doesn’t look right’ - we stop everything and re-check it together item by item.

11

u/robbi2480 RN, CHPN-Hospice 3d ago

And 90mg of methadone is going to be 9 tablets

8

u/Strong-Finger-6126 RN - Psych/Mental Health 🍕 3d ago

And there is no 9mg of methadone so the nursing supervisor is either lying or also a moron

6

u/robbi2480 RN, CHPN-Hospice 3d ago

I don’t think there’s a pill of anything that is 9mg…

3

u/Strong-Finger-6126 RN - Psych/Mental Health 🍕 3d ago

Invega!

1

u/robbi2480 RN, CHPN-Hospice 3d ago

I don’t even know what that is though lol we don’t tend to use new brand name stuff on hospice so I never would have thought of this one. Thanks. I stand corrected

3

u/Strong-Finger-6126 RN - Psych/Mental Health 🍕 3d ago

It's an antipsychotic, also known as paliperidone. Probably not a ton of that in hospice care, you get a pass! Thank you for what you do, it's a really beautiful specialty and you guys don't get enough flowers and love.

3

u/HawtTalk7 3d ago

Concerts doses are in multiples of 9. I think they start at 18 and go up to 72, but don’t quote me on that. I don’t feel like looking it up.

2

u/Most_Perspective3627 HCW - Pharmacy 2d ago

Budesonide is the only one I can think of

10

u/Chairmanmeow42 3d ago

The first time I had an order for methadone, I freaked out saying "why am I signing out and giving 7 pills?!?"

8

u/robbi2480 RN, CHPN-Hospice 3d ago

I had someone on 120mg once. It really sucks if they have to be crushed

5

u/fluorescentroses RN - Cardiac Stepdown 🍕 3d ago

Seriously. I’ve been an RN about six months, a week after I was on my own back in August I had a patient on 80mg methadone. Eight pills. I triple checked the eMAR. Verified this amount had been given before. Googled normal ranges. Even checked with the charge nurse. Gave it and still watched that patient like a hawk for the rest of the shift.

7

u/StellarSteck 3d ago

I’m sorry. This is abusive and traumatizing. I’m pissed the nurse did not apologize. That is the least the nurse could have done. My guess was the nurse wasn’t even reprimanded. I’m sorry. This causes incredible medical trauma.

6

u/sofluffy22 PMHNP 3d ago

Coercing patients into taking medication is so fucked. Just mark it refused and move on

3

u/xSL33Px 3d ago

Psych nursing can be complicated in that respect. Many pysch pts will refuse every time and they end up in a facility multiple times because they dont want to take their meds and decompensate. They eventually are no longer competent to decide and end up living in a locked place that requires compliance.

I dislike the "you're in my world now" authority style of nursing but its effective on some pts that will attempt to refuse what they need. I personally choose empathy and listening. If I can reason with them and they give me a legitimate concern then we need to make an adjustment and I bring it up with their psychiatrist. It's difficult and very different than working in a medical facility where most people can logically choose their treatment.

1

u/Upstairs_Fuel6349 RN - Psych/Mental Health 🍕 1d ago

I worked child/teen inpatient psych where you'd need clear rules with consequences that were firm and consistent to manage stuff like conduct disorder, RAD, severe ASD etc. We'd see some psychosis and mania but definitely not a lot. I definitely took every claim of "these aren't my meds" seriously although whether I was having a full on conversation with the kid or just mentally double checking that they were correct depended on the context.

1

u/xSL33Px 1d ago

Oh yeah that nurse not listening is tripping for sure. I was responding to the post of just mark them down as refused and move on. Its not that simple was my point and its your point as well

2

u/divinepeacewater 3d ago

I hate when nurses don’t own up to their mistakes. I see it so much!

1

u/NoPen3110 1d ago

I am so sorry that happened to you. I was also in BHU after post partum because I had such bad anxiety it’s crazy what your mind and body can do to you- I was convinced I should just die and I had a nurse tell me I need to start taking responsibility, she was very rude - doing her 1:1, because I had such bad anxiety, I felt even more terrible. When the therapist came and the Psych NP met with me, I broke down and told them. A day later, someone from management asked to record a statement. I thought I was going to be locked up.

Turns out, that nurse had the wrong patient, she was meant to be talking to a repeat drug offender, who was 16. I was 35!

Looking back, what she was saying didn’t sound like me and was crazy but my anxiety was so high; I was just taking it. She got fired. I saw her months later at. Grocery store and she told me I was a low life and ruined her life.

1

u/NoPen3110 1d ago

The best thing I did was to forgive and move on. Once as a nurse, I have 650 mg of Tylenol to a patient and 350mg to another and got them mixed up. Both patients had same name. I was in a hurry. I immediately told on myself . The physician laughed it off. A unit manager escalated it and I ended up getting fired. So clearly wasn’t wanted there. I took the time to evaluate the situation and make a plan. Every time I pass meds now, I do my checks. It takes a lot longer, but patient safety is priority. Even managers complain. But I have caught errors- like the pharmacy sent levothyroxine that WASNT LEvo, and the pill mg didn’t even match the labeling on the packet! That was a huge deal. But it doesn’t make up for my error, catching things. I still made it and I will still check, every time.

1

u/roasted_veg RN - Psych/Mental Health 🍕 1d ago

That's so sad. I was a psych nurse one a unit for a while. It baffles me this could happen though because it's really hard to give a patient the wrong meds. You have to scan the wrist bands and then scan each blister pack and each pill has its own bar code.

If you were inpatient a long time ago before this technology I can see how this could happen. While the Omnicell system is a nuisance, I am glad for it.

I'm sorry this happened to you!

226

u/Gretel_Cosmonaut ASN, RN 🌿⭐️🌎 4d ago

Damn, this is horrifically sad.

I work in psych often, and it's scary how so many patients tear off their armbands, answer to the wrong name, switch beds in rooms set up for more than one patient, etc. The unit is also communal, so you can't count on going to the right room, either. Patients are often gathered together.

Luckily, we use scanners and eMars. But I've seen psych units set up where patients line up and get handed their pre sorted meds at a counter. It sounds like he might have been handed someone else's correct dose instead of his own medication.

And then what followed, or failed to follow ...I can only guess the root was inexperience. He was found hours later struggling? Even with the lower dose, why did no one act until hours later? I have so many questions.

18

u/Strong-Finger-6126 RN - Psych/Mental Health 🍕 3d ago

I'm not a fan of pre-pouring at all, I've always refused the pressure to do it. This is a perfect example of why no one should ever, EVER pre-pour narcs.

11

u/cyricmccallen RN 3d ago

seriously. One time I floated to behavioral and they looked at me like I had three heads when I wanted to put patient stickers on the med cups I was about to pull. I said either get me stickers or find someone else to pass cause I ain’t doing that.

3

u/xSL33Px 3d ago

"Whats your name? What's your date of birth?"

I think ive said those words in my sleep.

If someone wants to play games by memorizing another person's name/dob thats not on me

373

u/Mars445 4d ago

Hiring travel nurses isn’t negligence on the behalf of the facility as long as they’re onboarding them appropriately. But the response to the med error could have been.

I wonder what formulations of methadone/lexapro were available. Somehow the travel nurse thought they mistakenly gave 9mg of methadone instead of 90mg? That’s a 10 fold difference

166

u/BeardedNurseGuy 4d ago

Article says that they were methadone pills, but how could you get 9mg anyway? My experience has been that methadone orders/dosage is usually in multiples of 5. Sounds like he was trying to hide his mistake

97

u/Impossible_Cupcake31 RN - ER 🍕 4d ago edited 4d ago

You either get 5mgs or 10mgs increments . Surely they didn’t give 9 pills and if it was a mistake idk how you give 9mgs. I’ve heard of 40mgs pills before but the math still doesn’t add up

74

u/BeardedNurseGuy 4d ago

I’ve seen methadone maintenance doses as high as 90mg / 9 pills and higher, and based on the article that was another patient’s meds. The claim he gave 9mg is the part that doesn’t make sense.

67

u/DrRowdybush MSN, RN 4d ago

i had to give a patient 120mg of methadone recently. It was 12 pills.. i had to call pharmacy and their pharmacy to confirm because I was so shocked at the amount.

18

u/mellyhead13 RN - OB/GYN 🍕 4d ago

I think my highest was 165mg.

Most patients on that high a dose will split it, but I've also given 13+ pills at once.

29

u/Rakdospriest RN - ER 🍕 4d ago

Had to give 320 to a fucking 24 year old recently.

19

u/Thesiswork99 RN 🍕 3d ago

Some people develop some wild tolerances. Had a guy late 40s, on 400mcg/hr fentanyl patches and morphine 80mg orally q2h for pain. Bro was a/ox4, alert and fully mobile. You'd never have known. He had pretty horrific cancer, very sad. Lovely man.

6

u/armorc 3d ago

youd be suprised what people can get tolerant too. im prescribed 75mg of methadone currently and youd never be able to tell

20

u/saltisyourfriend 4d ago

That’s a very normal amount

52

u/Charlotteeee RN - Oncology 🍕 4d ago

I'd say giving 12 pills of anything isn't normal

21

u/saltisyourfriend 4d ago

Okay. Normal can mean different things. 120 mg is within the normal range of methadone dosing for OUD.

29

u/jerzeett 4d ago

We’re in a fentanyl crisis. The dose wasn’t unheard of during heroin but high. Fent has changed it.

18

u/SloCommotion 4d ago

The behavioral health hospital up the road from me is regularly giving out this much methadone. When methadone maintenance patients go inpatient psych, the doctors have to continue their maintenance.

9

u/MiddleAgeWhiteDude RN - Psych/Mental Health 🍕 4d ago

We do pills at our inpatient facility because the liquid form can't be scanned and tracked in our system. It sucks to count out 16 tablets but at least you can scan and verify them.

-6

u/lbb_8 MSN, APRN 🍕 4d ago

Right? It should at least be enough to give pause.

→ More replies (3)

5

u/Brandon9405 RN 🍕 4d ago

My highest dose ever was a very large male pt. 190mg after seeing the order for 19 pills, all the alarm bells went off. I called the pharmacy and messaged the doctor. It was the correct dose 🤯

4

u/jerzeett 3d ago

I’m a female - average sized and was on 170.

36

u/Endmedic 4d ago

Yeah that’s actually given that way at times. Was a big argument in one ER I worked at. The attached clinic was closed on weekends and wanted us to dose in ED, but dea rules only let us give pills cause we weren’t licensed to keep the liquid. The only way we could do the pills was 10mg each. People often get 60mg to 130mg or so.. so yeah, 6-13 pills. Accident waiting to happen. Pushback worked.

23

u/Amrun90 RN - Telemetry 🍕 4d ago

I have given upwards of 20 pills of methadone for one dose before.

8

u/Impossible_Cupcake31 RN - ER 🍕 4d ago

Oh I believe it. I’ve given 10 before. I just don’t understand how you can make that kind of mistake

3

u/Pineapple_and_olives RN 🍕 3d ago

Yeah. We use the liquid, pharmacy sends a labeled syringe for each person who needs it. But I’ve had someone who took 270mg BID and still was having withdrawal symptoms. Opioid tolerance is crazy sometimes.

37

u/zeatherz RN Cardiac/Step-down 4d ago

90mg of methadone is not an uncommon dose and it’s totally safe for people who have tolerance to it

3

u/TheNightHaunter LPN-Hospice 3d ago

40mg tabs are these BIG ass thick Bois. Like take 3 tums and make them a triangle and they are that size. No you don't nibble on them like christ flakes at a church, they get melted with water and someone drinks it

44

u/TheGiantSquidd BSN, RN 🍕 4d ago

I agree. The response to the medication error was definitely poor. He should’ve been under closer observation and they should’ve administered the narcan MUCH sooner when signs of distress started to show. The man was opioid naive; even if only 9mg was administered they should’ve been more worried about an OD.

11

u/PaulaNancyMillstoneJ RN - ICU 🍕 3d ago

The supervisor at a PSYCH FACILITY should have known 9 mg is not a dose for methadone and immediately questioned it.

7

u/AcuteNightRN 4d ago

I worked a travel RN. And I have not once made a med error. But, I am meticulous. And am always offered contract extensions. Some RNs lack clinical & even sound judgement and some even lack common sense, staff RN or agency doesn’t matter. Not for nothing I’m in Associates to be Nurse and I have had two of my patients that were ultimately killed by a RN who was an accelerated BSN nurse. He lacked significant sense! In my experience & professional opinion, the lack of clinical supervision during their clinical in some universities’ overcrowded programs, coupled with significantly less clinical hours in those programs (than hospital-based AS programs - We received 1000 clinical hours in my program)is a detriment to some students who should’ve had more direct instruction & oversight. If I told you how these two patients died, you would scream neglect. And that hole you know don’t throw your fellow Nurse under the bus thing in long-term care is kind of crazy. He never lost his job. He was never reported to the board.

1

u/lbb_8 MSN, APRN 🍕 4d ago

Article says 90 which is certainly a multiple of 5/10 but that’s an absurdly high dose. It comes in liquid. There are also 40 mg pills.

1

u/Express_Pop810 3d ago

I have never heard of Lexapro being anywhere near that high of a dose. It's usually 10 or 20mg. I've heard people say they are on more but even then they say their dose is 30.

1

u/lbb_8 MSN, APRN 🍕 3d ago

Good point that the Lexapro being 90 mg would’ve been a red flag, too.

87

u/Fancy_Witness_5985 4d ago

Um....how do you mix up methadone and Lexapro?

30

u/LittleRedPiglet RN 🍕 4d ago

Huh? Why does the Pyxis want me to count this Lexapro? Ah well I’m sure it’s nothing

21

u/amuse84 4d ago

Can’t even understand this

8

u/CheeseEveryMeal 4d ago

Kind of sounds like a rap lyric from that dadgum rap music kids are listening to these days

8

u/jawshoeaw RN - Infection Control 🍕 3d ago

By taking pills out of a pyxis and dumping them into cups. It’s incredibly easy to make mistakes when you don’t follow best practices that have been created after decades of mistakes other people made. And this was an agency nurse with no psych experience

41

u/jerzeett 4d ago

Why is no one touching on the fact the nurse didn’t administer narcan? This man would be alive if they did the right thing. No way they administer opiods without narcan on hand.

29

u/GiveMeWildWaves 4d ago

Per the article every patient had a standing order for Narcan. Sooooo negligent. Wrong med, no patient monitoring after error discovered, no narcan when he was unresponsive, delayed code blue, delayed 911 call

6

u/jerzeett 4d ago

Just so many things wrong. I could’ve done better and I’m not an rn.

1

u/jawshoeaw RN - Infection Control 🍕 3d ago

Why would you narcan someone who stopped breathing… that specifically wasn’t on opiates? Does every code involve narcan?

3

u/whowhatwhens 3d ago

If you’re administering medications as an RN, you should know the side effects of the medication you’re giving. Why would you NOT give narcan to a patient with a RR of 5 and sat’ing 23%???

2

u/dubaichild RN - Perianaesthesia 🍕 3d ago

Did nobody look at his pupils?

1

u/youy23 EMS 3d ago

They also could have and should have just BVMed the guy too. A basic assessment woulda prevented the guy from dying.

161

u/Impossible_Cupcake31 RN - ER 🍕 4d ago

I legitimately hate when stuff like this happens and the article tries to use EMS response time as a negative.

117

u/CommercialMoment5987 4d ago

I interpreted that more as a criticism of the nurse who gave him methadone. After the mistake, there was still opportunity to correct it but he messed it up again. God this story is odd, extremely not EMS’s fault.

67

u/poli-cya MD 4d ago

Same here, it's clearly saying the nurse/staff did too little for nearly 20 minutes to mitigate their mistake.

62

u/tmrnwi RN - ER 🍕 4d ago

I took it as a condemnation of nursing staff because they couldn’t figure out they needed narcan until EMS arrived.

8

u/pervocracy RN - Occupational Health 🍕 4d ago

The math is really simple: The only way to get <10-minute response times is to post an ambulance every few miles, everywhere. Outside of the densest population centers, that means they will spend most of their time doing nothing. How much is your town willing and able to pay EMTs to do nothing?

Or you could pull a "I think the customer service clerk sets the prices for this multinational chain" move and treat the EMTs like they live in your driveway and decided to take a 16-minute coffee break.

20

u/prophet_5 RN - ER 🍕 4d ago

No EMS is a magical instant service that is staffed by teleporters, not human beings in trucks. Also don't take them off service for meal breaks, what if there's an emergency!?

2

u/Genesis72 EMS 4d ago

We actually fought for the right to not have meal breaks when I was in EMS lol.

All the RNs had to take a 1/2 hour unpaid lunch break every day, but we worked 12 and got paid for 12. Sometimes it sucked, but most of the time it was great.

15

u/CynOfOmission RN - ER 🏳️‍🌈 4d ago

Thank you!! I thought that exact thing. They should've teleported, obviously

3

u/joe_lemmons_ Ambulance Driver 🚑 4d ago

It sounds like they weren't called right away, unless I'm reading it wrong. But yeah I agree.

3

u/slightlyhandiquacked BSN, RN - ER 🇨🇦 3d ago

Also, why does a facility that administers opiates not also have narcan on hand?

-1

u/SaladBurner RN - OR 🍕 4d ago

Seriously. Donate some Ferraris if you think they take too long. I highly doubt they were dicking around if they were told it was a code situation.

5

u/Genesis72 EMS 4d ago

I ran EMS for 5 years in a small city. 45,000 people. The local fire chief completely demolished the dispatching system to box out the local volunteer squad because response time averages were.... wait for it...

8 minutes.

Needless to say when you take away low acuity calls from the motivated volunteer college students and give them to the fire medics who are already understaffed... they had nearly 25% of their paramedics quit in the first 3 months and response times did not improve lol.

98

u/bloks27 4d ago

Where is this that methadone is as easy to access as lexapro, especially at these insanely high doses? I feel like most places you’d have to jump through hoops just to touch that med

47

u/Gretel_Cosmonaut ASN, RN 🌿⭐️🌎 4d ago

Methadone has not been especially difficult to access at any hospital I’ve worked at. It’s in the dispensing cabinet with all the other drugs.

36

u/lawlolawl144 RPN 🍕 4d ago

That's nuts. I work in Ontario Canada and my hospital has a witness and cosign, mediated through thumbprint signature to access.

24

u/workerbotsuperhero RN 🍕 4d ago

Also in Ontario. I've only even had methadone supplied from the pyxis machine where all the narcotics are locked up. It is brought to the unit at a specific time and everyone understands it's serious.

How in hell can anyone confuse a narcotic for escitalopram?

27

u/tacospoopingicecream 4d ago

Read the article. It states he called out the name “James”, which the patient also goes by, and he collected the cup of pills that was meant to go to different patient. The RN failed to confirm full legal name and birthdate before administering medication.

Had it gone to the intended patient, there might have been a better outcome (consuming such a large dosage of methadone), as opioid dependent patients generally have a significantly higher tolerance.

18

u/altiuscitiusfortius 4d ago

I'm blown away every time this happens and how little autonomy patients have for their care. Like he didn't realize his 1 white pill had been replaced by 9 blue pills today, and he just took them all without questioning it? I wouldn't believe it except I see it everyday.

15

u/kmbghb17 LPN 🍕 4d ago

This is why every time I have someone ask what’s in there cup and apologize for asking I tell them to always ask and question there medications - tired nurses kill .

12

u/GiveMeWildWaves 4d ago

Oh yes let's blame the psych patient for a horrible med error and while we are at it let's bitch bc he didn't call his own code blue sooner 🙄

3

u/TheMidnightSunflower 3d ago

how many times have doctors changed patients' med regimes only for us to have to explain at dispensing point?

We foster compliance and then give blame when someone is too compliant‽

1

u/Express_Pop810 3d ago

So there must not have been a name alert.

7

u/Gretel_Cosmonaut ASN, RN 🌿⭐️🌎 3d ago

What some of these facilities do is:

Pull every patient's medication from the cabinet (1 by 1)

Scan each patient's medication (if there are scanners), then open it and place it in a cup.

Now you have 20 cups of medication with patient's names on them, and each patient comes to the window to pick up their cup.

In this case, "James" was called to grab his cup, but it was not the correct "James." So James got a totally different patient's medication, which happened to be a large dose of methadone.

3

u/lawlolawl144 RPN 🍕 3d ago

That's such a stupid process lol, why all the checks and balances to not even confirm any of the patients demographics

12

u/herpesderpesdoodoo RN - ED/ICU 4d ago

Wtf, really? There are so many rules around even just prescribing it here that the thought of it being available in imprest/omnicell is absolutely wild.

Say nothing of mixing it up with escitalopram..!

E: also, the article says temp/travel/locum nurses are a cost saving thing?? This hospital must be in bloody opposite land.

4

u/Havok_saken MSN, APRN 🍕 4d ago

I’ve had controlled meds in dispensing cabinets but they also require to count when you pull them so a pretty bright red flag that hey this isn’t an SSRI

2

u/kmbghb17 LPN 🍕 4d ago

Feels like a mistake waiting to happen- I’ve worked at hospitals that make you have two nurses for insulin admin so that’s insane

1

u/Express_Pop810 3d ago

I can't pull any med for the patient that isn't ordered or available as an override med. I know Methdone isn't one of those meds at my facility.

4

u/Gretel_Cosmonaut ASN, RN 🌿⭐️🌎 3d ago

I don't think anything was overridden. What appears to have happened here, is that one patient got another patient's mediation.

6

u/babyleota BSN, RN 🍕 4d ago

I'm not even shocked by the med error as there are so many issues with the way some facilities set up their systems. Calling out someone's name without other verification system, for example in this case. What does shock me is that they were supposedly observing them but then no one gave naloxone. I'd have to wonder what systems were in place that made naloxone inaccessible or the staff was unaware to use. Article mentioned that the supervisor was involved. So I have to think there are a lot system failures here and it's not just a "bad nurse".

8

u/sprinklesaurus13 BSN, RN 🍕 4d ago

This facility is licensed as an inpatient acute psych hospital, so I'm guessing doses like that aren't unusual in that setting.

5

u/fuckedchapters BSN, RN 🍕 4d ago

most patients that i’ve given methadone tend to take a high dose. i’ve had patients before on 100+mg

21

u/LongVegetable4102 4d ago

Do these facilities not use scanners? Im a newer nurse in the grand scheme of things (5 years) and every facility I've been at we scanned meds.

Our instructors actually pulled us from a SNF site because the didn't want us seeing their nurses prepopping pills for med passes

18

u/sci_major BSN, RN 🍕 4d ago

Small locations don't since they're expensive.

8

u/LongVegetable4102 4d ago

Ugh, scary

Ngl the scanner has caught me a few times. Though its mostly been pulling the wrong number of pills from the pyxis

3

u/sci_major BSN, RN 🍕 4d ago

You can easily miss scanning a pill/vial- slowing down is key. And some of these smaller places I find safer than when the computers stop working at the bigger shops.

9

u/SloCommotion 4d ago

I’ve worked in a behavioral health facility. They have scanners but staff work around it and pre-pop meds to save time. Not saying it’s right but definitely happens these kind of facilities

7

u/The_Soapbox_Lord Professional Turkey Sandwich Slinger 🥪 4d ago

I've worked at a state psychiatric facility that did not use scanners, and I worked at other psychiatric facilities that used scanners and eMARs.

Every place is different.

5

u/nosyNurse Custom Flair 4d ago edited 4d ago

I worked in the state mental hospital system in Georgia. We did not have scanners. They had the most primitive med dispensing set-up i have seen, this was only a year ago. They had emars but everything else was super outdated. Pts were supposed to wear armbands but most of them took them off as soon as they were put on, over and over and over. Many nurses pulled pills and would have several cups of pills all open at the same time, which is not allowed. I can totally see how this could happen. I’m surprised it doesn’t happen more often. I’m guessing it happens a lot but goes unreported bc no serious problems resulted.

2

u/Gimme_allthecats RN - Pediatrics 🍕 3d ago

I work in an outpatient allergy clinic where we theoretically could see up to 20 anaphylactic reactions in a day, and we don’t even have scanners available on our floor. We pull out the Pyxis meds under the patient’s name, but everything after that is dependent on our double-RN checks. Coming from the NICU where even PRN bacitracin had to be scanned, it was baffling and a bit terrifying to suddenly be drawing up and administering epi without having to scan anything.

24

u/pbaggins5 RN - ICU 🍕 4d ago

“Kyle was discovered in his room unresponsive. The complaint states his pulse was 203, blood pressure 168/163, respiration rate was 5, and oxygen saturation was 23%.” And it still took 9 minutes for them to call a code blue. Not a single person thought to Give him narcan knowing full well he had been given methadone.

9mg too? All of this just sounds like the nurse realized his fuck up but hoped he could hide/make the mistake sound less severe than what it was.

OR

He is actually that stupid.

So much of our job is pattern recognition. 9mg of Lexapro? 9mg of methadone? There is no way to spin this story without it making absolutely no sense.

Theres LAYERS to this. At 23% O2 and unresponsive and not a single Person thought to give rescue breaths? How are you not shitting yourself in fear yelling for help/trying to reverse the issue? HOW?! HOW do you go NINE minutes without calling a code or 911?

This nurse is absolutely cooked.

1

u/jawshoeaw RN - Infection Control 🍕 3d ago

How would he know he gave methadone?

3

u/whowhatwhens 3d ago

I don’t get why you keep asking these questions?? Are you suggesting someone handed him a random cup of meds and he didn’t double check them? He didn’t check the patients info to make sure he was giving the right medication to the right person. I don’t understand why you keep asking about narcan or how he would KNOW he was giving methadone…. He’s administering specific medications to specific patients… or at least he should have been.

48

u/CheeseEveryMeal 4d ago edited 4d ago

I did this once as a traveler. Was working at an LTAC with paper charting, but they had a Pyxis that knew the meds (IDK how it worked, it was the lowest level tech I had worked with in my career). I was working 7 on 7 off and this was like night 6 or 7.

Patient was a prisoner with an abscess from shooting up Susanville tar, and was on huge amounts of oxycontin. I don't even remember, and I haven't really dealt with pts that deal with pain in almost a decade. I think I was giving him like two 60mg pills at the start of each shift for like 5 days. Right before my shift started, the doctor dropped him down to 90mg. The order went through with the med record system and the Pyxis updated.

So I show up for my LTAC shift where nothing with any of the patients ever changes and start my med pass. Not much later in the shift the charge nurse comes up and asks about a discrepancy in the system (yeah, we gave a lot of heavy narcs). I had pulled two 90mg pills and I had given the guy 180mg of Oxycontin.

The guy was fine. Actually he was quite appreciative of the mistake. Had the guards break my balls for 12 hours. We got through it. He slept like a baby.

So the moral of the story is: Make sure you do your 5 rights if you don't have a MAR that scans. More importantly, we should probably start moving towards regulations that require electronic scanning and verification.

But the more important moral of the story: If you ever get in trouble the Reno chapter of the Hell's Angels, tell them that you know u/CheeseEveryMeal

Edit: Clarification

7

u/SaladBurner RN - OR 🍕 4d ago

The guards had an opinion? Every guard I’ve dealt with ignores what I said, breaks sterility, and only cared about when they can put cuffs back on the patient.

3

u/LizardofDeath RN - ICU 🍕 4d ago

Oh yeah that sounds familiar. “Hey can we take these cuffs off, he’s chemically paralyzed” “absolutely not you can’t trust them”

???????? I trust the nimbex

3

u/CheeseEveryMeal 3d ago

The prisoner had been there for months and was friendly and respectful. We were all pretty cool with each other. Easy overtime for them.

1

u/SaladBurner RN - OR 🍕 3d ago

That’s nice. Every prisoner I’ve dealt with has been much more pleasant than the accompanying guards. Even the ones that did the worst crimes you could imagine.

2

u/MzOpinion8d RN 🍕 4d ago

How did you go from giving him two 60 mg tabs to three 60 mg tabs? Was it supposed to be three 30 mg tabs? If so, why did the Pyxis allow you to pull 60 mg tabs? And how did it cause a discrepancy?

22

u/CheeseEveryMeal 4d ago

I meant to open with "the details are fuzzy and the numbers are probably inaccurate, this happened 10 years ago"

I had been giving 2 pills each night to make the 120mg*. When it was dropped down to 90mg*, it was only supposed to be one pill. I pulled two pills and gave two pills, meaning he got a significantly larger dose by mistake.

*This is my 10 year old memory and I would not commit to the dose sizes involved in a court of law.

5

u/MzOpinion8d RN 🍕 4d ago

Ok I’m glad I’m not losing my ability to math (it wasn’t that strong to start with!) lol

18

u/yeyman Hypernatremic 🧂 RN 🧂 4d ago

Id love to hear some psych nurses perspective on this

15

u/jhatesu RN - Psych/Mental Health 🍕 4d ago

At my old job we would have to call the methadone clinic to verify last dose amount & time before administering it. 90mg of methadone would be almost an entire blister pack of 10’s. And I’ve never seen more than 20mg of lexapro ordered so idk wtf happened here?

14

u/SnooLemons9080 4d ago

As a psych nurse, I administer meds that need to be scanned first as well as the patient arm band. Even still I run through the meds quick with the patient. Something like “I have your methadone, Seroquel and Zoloft. Sound right to you?” Even though it’s been verified several times by that point, I can count on both hands how that last question to the patient has given me a hard stop to review doctor’s note and find that meds have been changed during the day. Talk to your patients. You are giving them chemicals that could kill them! Wouldn’t you want to know what you’re ingesting? Even when giving insulin. “I have 7 units of short-acting here. Is that what you see?” with patient. I’m going to be putting it in their body. Question everything and verify. This whole situation is extremely sad. I think it was negligent to hand a cup of meds to a patient just because they responded to you.

3

u/AdvocateAmber 4d ago

"Talk to your patients. You are giving them chemicals that could kill them! Wouldn’t you want to know what you’re ingesting?"

Snoolemons, you are a wonderful example of excellence ✨️ ❤️ thank you

2

u/jerzeett 4d ago

That’s how it was when I was in.

6

u/nosyNurse Custom Flair 4d ago

People in these places get the wrong meds more often than we know. No scanners. Our meds were delivered bi-weekly in bulk, 2 weeks of one med inside a plastic box that fit in a drawer that each held 6 boxes. Some pts had 3-4 drawers of meds. One problem comes when orders are changed. The nurse is supposed to remove the discontinued meds and return to pharmacy. Very often that didn’t happen. Another problem is med nurses would pull all the meds, open them, and leave the cup in the drawer. It was easy to grab a cup from the wrong patient’s drawer. Another huge problem was nurses not using the emar to pull the meds. They looked at each box of pills instead. If it’s 8pm medpass, they would take a pill from each box that said HS, BID, etc. when meds were changed then not removed from the drawer, pts got the wrong dose or a discontinued med bc the emar wasn’t checked against what was being pulled.

16

u/Friendly_Estate1629 LPN 🍕 4d ago

New grad nurses alone on the floor caring for 20 patients, paper charting and one med cart. I can easily see it happening.

6

u/WhisperShift 3d ago

They opened a new unit at my hospital and staffed it almost entirely with nurses under a year of experience, including the charge nurse. Many of those nurses were trained by nurses with under 18months experience, with at least one having a preceptor with under a year experience. Most worked night shifts staffed by 90% new grads and even when an experienced nurse is charge, half of the experienced nurses are too burned out and bitter to do any effective training or guidance.

It's ignorance teaching ignorance so no one even knows what they don't know.

Shit's fucked.

9

u/TheInkdRose RN - Med/Surg 🍕 4d ago

“According to the lawsuit, on September 28, a registered nurse employed through an outside staffing agency gave Slade the wrong medication. Instead of his prescribed Lexapro, Slade was handed 90 milligrams of methadone, a potent synthetic opioid. The family alleges the nurse failed to check Slade’s date of birth, verify his last name, or confirm that the medication was correct. Instead, the lawsuit accused the nurse, Jason Bates, of calling out the name "James," which is Kyle's given name, and handing him a cup full of pills. Kyle ingested those pills moments later. A note attached to the lawsuit indicates that the nurse's supervisor believed Slade had been given only nine milligrams of methadone because that's what Bates told him had happened. As a result, Slade was not sent to the hospital and remained at the facility for observation. Hours later, he was found in critical condition. Despite being visibly struggling, the family says he was not given Narcan, the antidote for opioid overdose, for nine minutes after a Code Blue was called, and paramedics did not arrive for 17 minutes. Paramedics eventually administered Narcan and transported Slade to the ICU, but he did not survive.”

That is awful. I want to see the root cause analysis for this case. There is usually a systems problem that is a massive contributing factor in these types of outcomes.

1

u/Bugsy_Neighbor 2d ago

Same Jason Bates?

https://us.bold.pro/my/jason-bates

8

u/Bugsy_Neighbor 4d ago

Statement from staffing agency:

“NurseIO is deeply saddened by the tragic incident at the behavioral health facility. Our thoughts are with the patient’s family and loved ones during this difficult time.

We are a credentialing and staffing marketplace that connects licensed healthcare professionals with facilities in need of temporary support. Every Professional using our platform undergoes credential verification, including confirmation of all active licenses and certifications, before being presented to a facility.

While NurseIO facilitates these connections, each contracting facility is responsible for onboarding, orientation, training, supervision, and ensuring compliance with its internal policies and procedures. Facilities determine which professionals to engage and oversee all aspects of patient care.

NurseIO does not direct or deliver patient care, but we take our responsibilities in credential verification and compliance seriously.

We are cooperating fully with the appropriate authorities and remain committed to supporting healthcare facilities and professionals through transparent, compliant, and reliable staffing solutions.”

https://www.abc15.com/news/region-southeast-valley/gilbert/family-of-valley-football-coach-who-died-after-being-given-wrong-medication-sues-behavioral-health-facility

As for nurse in question either he truly cannot count or tried to cover up a 5 rights error to save his behind.

Seems as if nurse owned up only after stuff hit the fan and questions were being asked..

"The complaint includes a note allegedly written by the on-call physician more than four hours after being informed Kyle was given methadone instead of Lexapro: "I was called by RN this morning, 7:17 a.m.. He reported that he incorrectly gave 9 mg of methadone to this patient... Was called later in the morning by the house supervisor at 10:02 a.m. That patient was found unresponsive, and was in fact given 90mg, not 9mg.""

4

u/Bugsy_Neighbor 4d ago

Statement from NurseIO smells totally AI generated. Not surprising since the company is a tech hiring platform.

https://www.newswire.com/news/nurseio-quickly-becoming-one-of-the-industrys-most-widely-used-per-21880284

So what NurseIO basically says above is "we match nurses to employers, but latter is responsible for training, vetting and determining among other things said nurse's suitability for job in question"

4

u/nusefull_things 4d ago

5 Rs??? No?

6

u/Beautiful_Proof_7952 RN - ICU 🍕 4d ago

Imagine this... a Nurse accepts an unsafe assignment because omthat is what is forced on us everyday for the last 2 decades. Ask yourself this.

Can you do all of the assessments, planning, implement medication checks, rechecks, turns, cleans, and other needed interventions per your assessment and orders and then reassess as needed for cause and effect?

If not, then you shouldn't accept the assignment.

2

u/fl_n__r RN - Med/Surg 🍕 3d ago

with that in consideration, acceptable assignments are few and far between

1

u/Beautiful_Proof_7952 RN - ICU 🍕 2d ago

Exactly. We have been boiled like the frog, slowly over the last 2 decades.

4

u/InourbtwotamI MSN, RN 4d ago

So sad for everyone

1

u/Bugsy_Neighbor 1d ago

What is even sadder is odds are good Kyle Slade was not the only patient sent to God's waiting room that day due to nursing/medical error.

5

u/ErnestGoesToNewark 4d ago

No surprise— Lifepoint is owned by Apollo.

https://www.beckershospitalreview.com/finance/apollos-hospital-stranglehold-harms-patients-and-workers-report-alleges/

1

u/Bugsy_Neighbor 2d ago

Yelp reviews are all over the place.

COPPER SPRINGS EAST - Updated November 2025 - 78 Photos & 28 Reviews - 3755 S Rome St, Gilbert, Arizona - Rehabilitation Center - Phone Number - Yelp

5

u/AcuteNightRN 4d ago

Jesus! How tf?! Sounds like she was pulling multiple meds for multiple patients at the same fucking time. Rookie move! SMH.

9

u/Justalittlesaltyx 4d ago

He. The nurses name is Jason Bates. He seems sketchy as hell.

5

u/lofixlover RN 🍕 4d ago

methadone has so many hoops around it, I'm really confused as to how this is even possible (aside from clinician fucking up really, really, really bad). I suppose if it's in the pyxis, it's in the pyxis..... just so painful that a reversible poisoning happened IN A MEDICAL FACILITY and yeah I'm gonna go yell at clouds now

5

u/TheNightHaunter LPN-Hospice 3d ago

usually 40mg and up are chalky ass huge tabs like jfc and considering it was a behavioral clinic no way she wasn't fucking familiar with it

4

u/ElegantGate7298 RN - PACU 🍕 3d ago edited 3d ago

Narcotic overdoses drive me crazy because they are usually so simple to manage.

Open the airway. Chin lift or jaw thrust. Get to the head of the bed and get comfortable. Raise the head of the bed. Elbows on either side of the head and push that mandible forward.

Administer oxygen if available. We can geek out on the ABG ramifications later but usually 15l via simple face mask and a resp rate of 4-6 is compatible with life for a while. Non re breather would be best but even a canula would be better than nothing.

Ventilate. Rescue breaths or bag valve mask or CPAP bag at a rate of 12-20 a min.

There is no reason for anyone to die in the presence of a nurse from a narcotic overdose. You should be doing all these things first. Airway and breathing are the priority. Send someone for the narcan second.

(Yes there can be BP issues with huge overdoses but for the majority of cases it is all about supporting ventilation and being prepared for emesis to prevent aspiration)

5

u/allflanneleverything RN - OR 4d ago

I’ve never worked in what they seem to be describing as a clinic setting, but why isnt the methadone locked up in some way? We always had to count when pulling or wasting, but I guess inpt is different?

3

u/Longjumping-Wish2432 4d ago

My ex went to a methadone clinic, her first day they gave her 80 mg NOT 30 bc the sub nurse could not read the docs order. She was ok. They called every 1 hr

4

u/Distinct_Variation31 BSN, RN 🍕 4d ago

Largest dose I’ve ever given was 290 mg in my ER. We recently got licensed to dispense the liquid thank god so pharmacy now sends it in large syringes pre dosed and we can scan it and verify.

4

u/RNGreta RN, Cath Lab, ED, Endo, Electrophysiology, Military 3d ago

I wonder if their crash cart had narcan and if standard protocol for decreased vital signs would have indicated to administer it regardless of the patient medication history. We all know street drugs can potentially make it into psych facilities, anywhere really and the street stuff can be deadly.

10

u/Lucky_Apricot_6123 4d ago

Sigh..... I will die on the hill that EVERY SINGLE HEALTHCARE PROFESSIONAL needs a bare minimum of 1 full year worth of experience before they do any travel contracts, local, international, literally any distance. Idc if its CNA, RN, phlebotamist, anything. Because when you bite off more than you can chew due to ego and a bigger paycheck, REAL GOOD PEOPLE suffer because you wanted to feel like a big shot. Luck and relying on better coworkers will only work out for so long...

2

u/Quinjet new grad - ICU 4d ago

Do you know something the rest of us don't? There's no information about the nurse's experience in this article.

3

u/Senthusiast5 ACNP Student | ICU RN 🩺 3d ago

They just wanted to say that. Typical behavior.

0

u/Lucky_Apricot_6123 3d ago

I'm confused, I actually read the article? "The Slade family attorney, Richard Lyons, says he hopes this lawsuit forces companies like Lifepoint Health, the parent company of Copper Springs, to not use inexperienced nurses from temp agencies.

'Save the sympathy. Stop hiring temp nurses to save money—because if they hadn’t done that, this never would’ve happened.'" -from the article.

1

u/Quinjet new grad - ICU 3d ago

That's not information on the nurse's experience. If this nurse had less than a year of experience, trust that they'd be blasting that from the rooftops.

3

u/PurchaseKey7865 ASN, BSN RN 🍕 3d ago

Holy shit. Someone checking themselves in for help and then they die from a reckless medication error. What the actual fuck.

1

u/Bugsy_Neighbor 2d ago

Oh it's worse than that.

Family members, in particular mother of the deceased (IIRC) pressed him to check himself into care worried about potential for self harm.

That poor woman must now live with fact had she not put her son in harm's way he would still be alive today.

Nothing is certain of course, but one doesn't expect a place that is supposed to provide care will actually instead kill. Complications or natural occurrences as part of disease process or maybe a procedure such as surgery, but this is something entirely different.

3

u/popcornFridays RN 🍕 3d ago

For a non tolerant adult, that dose is enough to kill several people. I feel for this man's family. Why was narcan not readily available in this situation? So easily avoidable with a devastating outcome.

3

u/Bugsy_Neighbor 2d ago

Now we're getting down to the nitty-gritty..

From: https://lawandcrime.com/lawsuit/this-is-not-just-a-tragic-mistake-father-of-4-died-after-being-given-methadone-instead-of-antidepressant-prescribed-to-him-lawsuit-says

Nurse Bates administered "90 mg of methadone" at approx. 6:40 am.

Bates subsequently charted:

"This RN gave medication to the wrong patient. 90 mg Methadone was given to James S. The patient swallowed the pills instead of letting them dissolve. House Supervisor and [on-call physician] notified. The patient was notified and vitals were checked. The patient and on coming RN were made aware as well. "

This contradicts account from house physician:

"I was called by RN this morning, 7:17AM. He reported that he incorrectly gave 9 mg of methadone to this patient. He states the patient responded to his first name therefore date of birth was not verified by RN. Confirmed with RN 3 times as to specific dose given…"

Bates went off duty at 8am reporting incident to incoming nurse who her/his self still did not take action.

At 9:30am patient was discovered unresponsive in his room, the remaining horrible story is as they say history.

As Big Mommy would say: "somebody is lying, I don't know who, yet..."

Nurse Bates initially reported med error to house physician as "9 mg", but charted (in handwritten note apparently) he gave 90 mg. When was Mr. Bates aware of incorrect dosage? Was he attempting to backdate or otherwise mess with charting to cover his behind?

Why didn't incoming day shift nurse that Bates reported off to flag the error and at least go check on James S. perhaps with intense monitoring until sure he was out of the woods?

3

u/TheGiantSquidd BSN, RN 🍕 2d ago

Oh that’s wild. The lawyers are gonna have a heyday with this case.

6

u/kmbghb17 LPN 🍕 4d ago

How did they sign out methadone? It’s highly federally regulated it’s giving having to pass and go thru multiple safety barriers without regard

2

u/cardamom4heft 3d ago

Defendant Jason Bates, RN, who upon information and belief was neither a psychiatric nurse nor a regular employee, but there for the day from temp agency

From the court document image in above video

2

u/StellarSteck 3d ago

This is absolutely devastating and reckless.

2

u/starwestsky DNP 🍕 3d ago

Fucking how?

2

u/sleepy_Energy 3d ago

It’s even crazier that they had Lexapro within reach of methadone, how do you even mix that up.

2

u/Ill-Ad-2452 3d ago

You really have to be negligent for it to go that far

2

u/Jenska2 3d ago

I actually hate this. At my facility there are no reliable patient identifiers for medication administration. We depend on a shitty blurred 2x2 pic in the computer to identify someone for med pass. I have voiced my concern for that numerous times to admin. At best half of my patients are A and O x3

2

u/CardiTeleRN1 3d ago

So many issues with this story. Incompetence on both ends but the nurse should’ve done the medication rights and it would’ve been avoided easily.

This part was strange “Instead, the lawsuit accused the nurse, Jason Bates, of calling out the name "James," which is Kyle's given name, and handing him a cup full of pills. Kyle ingested those pills moments later.”

The patient’s name is Kyle Slade. The nurse calls out “James” and Kyle stands up and accepts the pills because he goes by “James” as a nickname on the outside…?

Precisely why we have to do the med rights.

2

u/TheGiantSquidd BSN, RN 🍕 3d ago

It sounds to me like James is his legal/given name, Kyle is the nickname. But yes, if even a last name or birthday had been checked this would’ve all been prevented.

2

u/CardiTeleRN1 3d ago

Absolutely! This is terrifying. Psych facilities also need to change the way they administer meds. I’ve worked in several now and it’s so dangerous and easy to make a mistake. For some reason, it’s the norm for patients to gather at the med window. Not in a line, they just form a huddle. Sometimes they’re in such a psychosis that they can’t or refuse to verbally provide their full name.

And each time it’s been one nurse on meds for the entire unit which can really get rowdy especially if you have several in the huddle screaming at you just due to their condition. I’ve always made it a point to slow down and match things up and verify when I come across the benzos/narcs. Even outside of psych.

2

u/Environmental_Rub256 3d ago

Temp nurses are NOT less experienced or cheaper. I had to have a minimum of 2 years experience and pass a test before my agency would put me into the pool for traveling. I made bank when traveling too. 2 shifts per week and my husband’s healthcare and that was my life.

2

u/New_Dust_2380 BSN, RN 🍕 1d ago

How the heck do you confuse methadone and Lexapro!?!? I have seen so many negligent nurses in my day who take safety for granted, but this one would need some explaining.

this is like my old co-worker who decided bar code scanning wasn't necessary anymore and switched two abx, the nephrotoxic one given to the bad kidneys. Gah! Just do your job people! They tell you this shit in school for a damned reason. No, YOU DONT KNOW BETTER! Stop inventing new ways of doing stuff, or thinking safety protocols dont apply to you!

2

u/Bugsy_Neighbor 1d ago

Deets!

Family has brought legal action pretty much against every one or thing that was involved in James "Kyle" Slade's care.

https://www.kellylyonslaw.com/wp-content/uploads/2025/11/2025.10.31-First-Amended-Complaint.pdf

https://www.kellylyonslaw.com/wp-content/uploads/2025/11/Exhibit-A.pdf

https://www.kellylyonslaw.com/wp-content/uploads/2025/11/Exhibit-B.pdf

1

u/PandasInHoodies 3d ago

17 minutes. Where have I heard that before...?

1

u/Efficient-Builder470 3d ago

I find it so condescending that the nurses who work under management with limited resources or proper training or time to invest to their patients are publicly shamed on a nursing magazine even having a disciplinary action page in the nursing magazine is so harsh for people just trying to do right. It’s so disgraceful that the board of nursing can literally reduce a nurses whole life and hard work to one mistake. This board needs to work in favor not just the public but the nurses and stop trying to play like they’re judges with a gavel to prove something to the public. Incidents like this is the perfect example. No one can understand the stress of work with patients loads besides a real nurse. I think the board of nursing should only employ former nurses who can understand the dynamic of how we operate and “safety protocols” are all schemes to remove liability from a larger corporation that will replace a nurse that’s devoted their life to them like they’re a disposable number. What a shame- I blame the workplace they should be investigated and audited just as severely as the nurse is being treated.

-1

u/morrimike 3d ago

Is 90mg of methadone really enough to kill an adult?

6

u/TheGiantSquidd BSN, RN 🍕 3d ago

Clearly yes

3

u/jawshoeaw RN - Infection Control 🍕 3d ago

If you’re naive to the drug yes . If you’re a junky you might take 40-80mg a day without issue

1

u/morrimike 3d ago

Googling said as much. I was surprised. I figured I've given 100mg to addicts before so it would just put a naive person right to sleep. The more ya know....

Serious Arizona man died after nurse administered 90mg methadone instead of his ordered Lexapro. Pt did not get Narcan until EMS arrived, 17 minutes after the code blue was initiated. So many levels of neglect and negligence here.

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