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

i have encountered many situations in which the wrong med was in the wrong drawer... i just look @ the little blinking lights * we have omnicell* same thing... i still call it a pyxis..cause thats what i was raised with... we have these really nifty heparin flushes...they are this yellow syringe... we often run out of them and there are some of the older vials in there... both 10mls.... we also have heparin boluses that are in the vials.. well... i was pulling up some *flush* heparin and noticed that it was indeed not a low dose flush but actual heparin....
i about wet myself cause i was so glad that i caught it because i was in such a hurry.. it can get crazy in an er... we all know that... but one must always.. ALWAYS double check the med you are drawing up or whatever....

oh.... and i want to make a real quick vent...

I HATE AMPULES!

why should we have to deal with rotating them so all the med is down there... then break off the top. *adds one more sharps hazard* then use a stupid filter needle to draw it up.. then change it back to a regular needle... or a blunt needle... my hospital has gone pretty much needlesess which took me a while to get used to but i really have grown to love the needleless system of stuff.... anyway....
I HATE AMPULES... i can do it in like a matter of seconds.... but just stick it in a vial!!!!

i told my sister about this... she works for a big pharmaceutical company in research and development.... you know what she told me?
*thats not my deal.... its probably a chemical thing.*

i told her... WELL YOUR JOB IS TO FIX IT!!!....
then she proceeded to tell me.... uhhh... you are my LITTLE brother.. nor do you write my paycheck..... now go on nurse.... if you want a job.. let me know... you can make real money here....

yup,... is that not horrible?.... fyi.. my sister was an RN in a burn unit for like 5 years... then got recruited to be a pharm rep... which she did... then 10 years later she is in research???

sorry... im venting....

but yeah... ALWAYS check those meds that you get out of a pyxis or omnicell.... ALWAYS!!!!

I can't even begin to count the number of times the wrong med has been in the wrong place. We spend at least an extra 30 minutes having to get meds together because we have to double check everything! We have a new pxyis system and it is causing more hassle than we ever anticipated. I also don't appreciate calling the pharmacy during off hours and being told to call the doctor to get a med changed to another form so they don't have to come in.

I remember a week ago I found some Dilantin in the cubbie with some senna. It takes me a while to pull my meds because I compare it with the screen and the med rec screen in our charting system. I usually let people go ahead of me if I don't need to give a med right away.

We have it happen often too, and you'd better believe if was nursing error related, the fur would fly so to speak.

We have even found narcotics in pocketc that already had non narcs in it, the whole 9 yds.

Anne, RNC

Yep - 3 times in just over a year as a nurse. MOM in the Maalox slot (stocked in neighboring cubbies - poor design). Was sent up a bag of meds labeled "compazine" on the outside, but the individual blister packs were actually Phenergan. Found 200mg theophylline in the 300mg cubie just last week. No problems with narcotics to date.

Pharmacists/Rx techs are mere mortals, too - that's why we are supposed to independently check the 5 R's.

Remember about 10-12 years ago when 30 mg high-dose epi vials were all over ACLS? We were working up an MI case when he arrested. Defib, 3 mg 1:1 epi, CPR, another shock. We decided to give 5 mg epi and as I was pulling up the dose, the syringe plunger wouldn't move. I looked down and realized I had a vial of Lasix. Instead of the epi, I had given him 60 mg of Lasix. The MD said not to worry about it, made no difference in outcome (only 3 minutes went by from when he should have gotten the 1st does of epi until when he actually got it--and the arrest was witnessed on the monitor so he was shocked within 30 seconds of deteriorating into v-fib).
But the big issue was: you've got two, rather large brown vials with orange-yellow tops setting next to each other in the drawer. We put a yellow sticker across the top (for urine) on the lasix.
maybe I'm lucky but I haven't seen any misplaced meds in a long, long time.

and nghtfltguy, I hear ya about ampules. If it's a cost thing, then the pharmaceuticals could make less commercials each year and afford to package their products more conveniently!!

Found morphine vial in the percocet drawer. Just showed it to a coworker as a witness and pulled it out and gave it to the Charge Nurse and told him what happened. I don't know why that one vial was in there. We had just hired a load of new nurses. I suspect someone just got frustrated trying to do a return and put it in the drawer when they got percocet out, but I don't know.

Mahage

How come those that fill the Omni are pharm techs who need no witness to fill it? We take a med out and have to waste it with a witness. What stops one of them from pocketing a med and then blaming it on us? I mean it probably won't happen (or from an impaired nurse from blaming it on the tech if they divert?-They SHOULD have a witness---protects them and us I mean seriously@! ) We go to school for AT LEAST two years and they just get handed meds and are trusted to put them in and not get blamed if it is off?

just had my first problem with this recently. I was pulled to another floor for the night. I have been on this floor many times before so I knew the nurses. I pulled my 10pm meds from the pyxis. I went to give my pt. 0.5mg of xanax and when I did the bedside check of the med before I administered the med I noticed I had a 0.25mg of xanax still in the pill pack. I always do multiple med checks before I administer the med. I said to the pt. I would be right back. Took all of the pills I had for 10pm meds still in their packaging and went back to the pyxis I pulled the med from. I logged in, brought up the pt and the meds. I saw the xanax 0.5mg on the screen profiled for the pt. it was the ONLY xanax order for the pt which I made sure and even checked the chart 2 times, I touched the xanax 0.5mg on the screen and the drawer opened, the cubie pops open and I pulled out what was susposed to be 0.5mg of xanax and checked ALL the pills. Yea there was an awesome mix of 0.5mg and 0.25mg of xanax in the same cubie.

Ok since this is NOT my regular floor, I made sure I checked what I was doing like 4 times. I said to the charge nurse there is a problem with one of your pyxis in the back. Now this floor has 3 pyxis machines. I showed her and 2 other nurses the med problem. I explained that I pulled a 0.25mg of xanax from the 0.5mg xanax cubie and showed the charge the ridiclous mix of 0.25and 0.5 xanax mixed in the same cubie. We went into the med log in the pyxis to see if someone retured xanax to the wrong drawer..NOPE. The last person before me to access that specific cubie was the pharmacy for med refill.

What a pain in the rear. We had to call the pharmacy and they had to come reconcille the problem. We had to check all 3 pyxis machines to make dure that the 0.5mg and 0.25 mg xanax were in the correct pockets in all 3 pyxis machines. Now this was well after shift change and narc counting that was done at 7pm. It must have happened when they did the med pocket refills around 8 or 9 pm. All 3 pyxis machines had the same problem with xanax, they were all mixed up. 0.5 and 0.25 were in the same cubie. The person who must have refilled them must have gotten the two dosage strenghts mixed up or wasn't paying attention. Even the nursing supervisor at night had to come and see what happened.

THANK GOD I ALWAYS double and triple check my meds before I administer them. The chrage nurse on that floor said to me..good catch Ang, I can tell your director that you discovered a major med. error b/c you are an observant and great nurse for catching something that could have been a major problem.

I said thanks, but also thought, I know sometimes we rush through med administritation b/c we may be be behind or just trying to give them on time, but how many of us just pull from the pyxis, assuming the machine is right and just give the med with out actually looking at the packging, or just give a glance at the packging, ok it's the right med, but don't really pay attention to the dose? We just assume that the med in the pocket that flipps open is the right med, or dosage?

One thing I have learned is always check and re-check your pt. meds no matter what.