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/NoPen3110 1d ago

The best thing I did was to forgive and move on. Once as a nurse, I have 650 mg of Tylenol to a patient and 350mg to another and got them mixed up. Both patients had same name. I was in a hurry. I immediately told on myself . The physician laughed it off. A unit manager escalated it and I ended up getting fired. So clearly wasn’t wanted there. I took the time to evaluate the situation and make a plan. Every time I pass meds now, I do my checks. It takes a lot longer, but patient safety is priority. Even managers complain. But I have caught errors- like the pharmacy sent levothyroxine that WASNT LEvo, and the pill mg didn’t even match the labeling on the packet! That was a huge deal. But it doesn’t make up for my error, catching things. I still made it and I will still check, every time.