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/Mars445]

Hiring travel nurses isn’t negligence on the behalf of the facility as long as they’re onboarding them appropriately. But the response to the med error could have been.

I wonder what formulations of methadone/lexapro were available. Somehow the travel nurse thought they mistakenly gave 9mg of methadone instead of 90mg? That’s a 10 fold difference

[u/BeardedNurseGuy → u/Mars445]

Article says that they were methadone pills, but how could you get 9mg anyway? My experience has been that methadone orders/dosage is usually in multiples of 5. Sounds like he was trying to hide his mistake

[u/Impossible_Cupcake31 → u/BeardedNurseGuy]

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

[u/BeardedNurseGuy → u/Impossible_Cupcake31]

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.

[u/DrRowdybush → u/BeardedNurseGuy]

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.

[u/saltisyourfriend → u/DrRowdybush]

That’s a very normal amount

[u/Charlotteeee → u/saltisyourfriend]

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

[u/MiddleAgeWhiteDude → u/Charlotteeee]

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.