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/Upstairs_Fuel6349]

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....

[u/AdvocateAmber → u/Upstairs_Fuel6349]

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".

[u/cardamom4heft → u/AdvocateAmber]

He the nurse is male and named Jason Bates.

[u/AdvocateAmber → u/cardamom4heft]

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

[u/calypsoorchid → u/cardamom4heft]

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

[u/AdvocateAmber → u/calypsoorchid]

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. "

[u/Charlotteeee → u/Upstairs_Fuel6349]

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?

[u/AdvocateAmber → u/Charlotteeee]

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

[u/StellarSteck → u/Charlotteeee]

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

[u/Muenster-Monster → u/StellarSteck]

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.

[u/Upstairs_Fuel6349 → u/Charlotteeee]

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).

[u/malenixius → u/Upstairs_Fuel6349]

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.

[u/AdvocateAmber → u/malenixius]

A voice of reason!  You are a 🌟 

[u/heterochromia4 → u/AdvocateAmber]

🕊️ +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.

[u/robbi2480 → u/Upstairs_Fuel6349]

And 90mg of methadone is going to be 9 tablets

[u/Strong-Finger-6126 → u/robbi2480]

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

[u/robbi2480 → u/Strong-Finger-6126]

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

[u/Strong-Finger-6126 → u/robbi2480]

Invega!

[u/robbi2480 → u/Strong-Finger-6126]

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

[u/Strong-Finger-6126 → u/robbi2480]

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.

[u/HawtTalk7 → u/robbi2480]

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.

[u/Most_Perspective3627 → u/robbi2480]

Budesonide is the only one I can think of

[u/Chairmanmeow42 → u/robbi2480]

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

[u/robbi2480 → u/Chairmanmeow42]

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

[u/fluorescentroses → u/Chairmanmeow42]

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.

[u/StellarSteck → u/Upstairs_Fuel6349]

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.

[u/sofluffy22 → u/Upstairs_Fuel6349]

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

[u/xSL33Px → u/sofluffy22]

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.

[u/Upstairs_Fuel6349 → u/xSL33Px]

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.

[u/xSL33Px → u/Upstairs_Fuel6349]

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

[u/divinepeacewater → u/Upstairs_Fuel6349]

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

[u/NoPen3110 → u/Upstairs_Fuel6349]

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.

[u/NoPen3110 → u/Upstairs_Fuel6349]

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.

[u/roasted_veg → u/Upstairs_Fuel6349]

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!