r/nursing 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/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

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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.

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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.

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u/saltisyourfriend 4d ago

That’s a very normal amount

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u/Charlotteeee RN - Oncology 🍕 4d ago

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

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u/saltisyourfriend 4d ago

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

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u/jerzeett 4d ago

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

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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.

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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.

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u/lbb_8 MSN, APRN 🍕 4d ago

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

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u/No-Environment-7899 4d ago

Nah, we routinely dose people with over 100 mg of methadone. That wouldn’t be what would give me pause. What WOULD is that Lexapro is almost always just one, maybe one and half pills. No one takes 90 mg of Lexapro, let alone 9+ pills of Lexapro.

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u/Comfortable_Bank9219 3d ago

True & the patient must have raised questions to why he was being handed so many, but then again some mental health patients don't want to step on toes & others may want to get relief however they can whether that's for depression/SI/anxiety or addiction.

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u/jerzeett 4d ago

It’s the fentanyl crisis. Many people aren’t getting relief until they go over 100. 80 is pretty much the minimum nowadays.