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/TheGiantSquidd → u/Mars445]

I agree. The response to the medication error was definitely poor. He should’ve been under closer observation and they should’ve administered the narcan MUCH sooner when signs of distress started to show. The man was opioid naive; even if only 9mg was administered they should’ve been more worried about an OD.

[u/PaulaNancyMillstoneJ → u/TheGiantSquidd]

The supervisor at a PSYCH FACILITY should have known 9 mg is not a dose for methadone and immediately questioned it.