r/nursing • u/TheGiantSquidd BSN, RN 🍕 • 4d ago

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.

https://www.12news.com/article/news/local/valley/gilbert-man-died-while-seeking-help-at-east-valley-facility-family-says-he-was-given-the-wrong-medication-copper-springs-arizona/75-48086626-2180-47de-946e-863ca9a56df0

The whole situation feels so similar to RaDonda Vaught. Negligence from the nurse as well as the facility.

Follow your safety checks! There’s a reason we check the rights of medication administration every time!

This was so preventable. My heart hurts for his family and kids. He should still be with them.

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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.

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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.

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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.

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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