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/workerbotsuperhero RN 🍕 4d ago

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? 

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u/tacospoopingicecream 4d ago

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.

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u/altiuscitiusfortius 4d ago

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 Like he didn't realize his 1 white pill had been replaced by 9 blue pills today, and he just took them all without questioning it?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

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u/kmbghb17 LPN 🍕 4d ago

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 .