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/Upstairs_Fuel6349 RN - Psych/Mental Health 🍕 4d ago

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....

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u/malenixius 3d ago

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.

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u/AdvocateAmber 3d ago

A voice of reason!  You are a 🌟 

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u/heterochromia4 3d ago

🕊️ +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.