Ever pull the wrong med from the right cubie in the Pyxis?

Potassium

The 10 mEq and 20mEq bags were in each other's slots.

EEk!!!

Often enough. What I love is when you contact Pharmacy the response you get is " Thanks for following the 5 R's". That's Special
My response is something like... I know the 5 R's, can your team read?
What really gets my goat is when I have to call Pharmacy and tell them we are out of a medication. The system has a par level and it should be set.
Why do we (the nurses) have to do everyones work?

ok if we pulled the wrong medication from the pyxis , arent we supposed to scan the barcode and check if we have pulled the right medication?

I pulled D5 from the NS compartment on our IV pyxis.

Yeah went to grab a bag of NS the other night, and it's a good thing I always check the labels because it was 0.45% NS.

Yes, but I didn't notice that it was Dilaudid that I'd pulled from the Morphine section. I was giving it slowly, and noticed my patient was getting way more stoned than I'd anticipated. I cut the dose short, and only after that discovered that the wrong med had been in the machine. That mistake helped pharmacy track a bunch of other errors to the same tech, who is no longer with us in that capacity.

Fortunately, it was at least a similar narc pain med, and I gave it slowly; so no real harm done. The possibilities scare me, though. Now, I check EVERYTHING coming out of that machine.

We have a little game called 'which med will be missing from the Pyxis tonight?'

I think the largest error potential are the drawers in the pyxus where all the cubicles are open when the drawer opens, it is very easy to put meds back in the wrong cubicle and that is where i have found the most errors.

Other then that our Morphine Sulfate and Hydromorphone syringes look identical, the only difference is the words printed on the label.

Thank goodness for all our checks. At the hospital where I work we are all computerized and scan the medications into the computer so it's sort of like an extra check. An error message will come up if it's too early, too late, wrong dose, med order not found, etc etc.