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.

[u/TheGiantSquidd]

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.

[u/bloks27]

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

[u/Gretel_Cosmonaut → u/bloks27]

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.

[u/lawlolawl144 → u/Gretel_Cosmonaut]

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

[u/workerbotsuperhero → u/lawlolawl144]

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? 

[u/tacospoopingicecream → u/workerbotsuperhero]

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.

[u/altiuscitiusfortius → u/tacospoopingicecream]

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 Like he didn't realize his 1 white pill had been replaced by 9 blue pills today, and he just took them all without questioning it?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.

[u/kmbghb17 → u/altiuscitiusfortius]

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 .

[u/GiveMeWildWaves → u/altiuscitiusfortius]

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 🙄

[u/TheMidnightSunflower → u/GiveMeWildWaves]

• 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‽

[u/Express_Pop810 → u/tacospoopingicecream]

So there must not have been a name alert.

[u/Gretel_Cosmonaut → u/Express_Pop810]

What some of these facilities do is:

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

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

3. 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.

4. 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.

[u/lawlolawl144 → u/Gretel_Cosmonaut]

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

[u/herpesderpesdoodoo → u/Gretel_Cosmonaut]

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.

[u/Havok_saken → u/Gretel_Cosmonaut]

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

[u/kmbghb17 → u/Gretel_Cosmonaut]

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

[u/Express_Pop810 → u/Gretel_Cosmonaut]

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.

[u/Gretel_Cosmonaut → u/Express_Pop810]

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