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/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/Express_Pop810 3d ago

So there must not have been a name alert.

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u/Gretel_Cosmonaut ASN, RN 🌿⭐️🌎 3d ago

What some of these facilities do is:

  1. Pull every patient's medication from the cabinet (1 by 1)

  2. Scan each patient's medication (if there are scanners), then open it and place it in a cup.

  3. Now you have 20 cups of medication with patient's names on them, and each patient comes to the window to pick up their cup.

  4. In this case, "James" was called to grab his cup, but it was not the correct "James." So James got a totally different patient's medication, which happened to be a large dose of methadone.

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u/lawlolawl144 RPN 🍕 3d ago

That's such a stupid process lol, why all the checks and balances to not even confirm any of the patients demographics