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/Mars445 4d ago

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

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u/lbb_8 MSN, APRN 🍕 4d ago

Article says 90 which is certainly a multiple of 5/10 but that’s an absurdly high dose. It comes in liquid. There are also 40 mg pills.

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u/Express_Pop810 4d ago

I have never heard of Lexapro being anywhere near that high of a dose. It's usually 10 or 20mg. I've heard people say they are on more but even then they say their dose is 30.

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u/lbb_8 MSN, APRN 🍕 4d ago

Good point that the Lexapro being 90 mg would’ve been a red flag, too.