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

Speaking as a former pharmacy tech, I think the biggest error I've ever come across happened when a *new* pharmacy tech was delivering narcotics to all the Pyxis machines. She got to the PACU and accidentally mixed up the fentanyl and sufentanil (sufentanil is 10 times more potent than fentanyl). The awesome nurses down there caught it and called us. When a pharmacist and I checked the computer to see if any had been taken out since it was restocked, we noticed an anesthesiologist had taken one for a patient.

Thank God he hadn't given it yet and we were able to get a hold of him...

Our hospital has a high turnover rate for pharmacy techs, and some of them don't have previous experience and/or their certification yet. I always double-check everything when I'm pulling meds for clinicals. I love the pharmacists and the techs, but the volume of drugs they're working with and the number of orders they fill on a daily basis is staggering.

My teacher always says nurses are patients' last defense...and I'd believe it!

yep and discovered that this incorrect med had already been administered to the patient a couple times...

Yes & I'm sure I will in the future.

Yep, put in for percocet and drawer for morphine opened. Notified pharmacy. Next night, it did it again. Notified pharmacy.
Mahage

God bless the Pixis. Not only have I found the wrong medication in the cubicles. I have found a wrong dose put in the cubicle. Pockets which show they have opened therefore the med was given, ah no the pocket did not open had to try try again.

No rest for the weary, always check the labels of the packages you are pulling name and dose. We have to remember humans fill the cubicles therefore are subject to error. Machines malfunction therefore are subject to error.

Yes, and this is why I'm glad my hospital uses the 'scanner' method at the bedside. That's the extra red flag I need as a new nurse to help me not give the wrong med!

Recently I have found 40mg tabs of Lasix mixed in with 20mg tabs and the exact same scenario with Lipitor. I addressed this with my supervisors, pharmacy, and other nurses to alert them. I pulled the med and pharmacy sent it back. They said to put it back and they would "fix it". yeah right. Handed it to the supervisor and filled out an incident report.