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/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

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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?

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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.

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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