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

Yep. More than once.

Usually I find myself taking one tab of what ever, but having typed in (and needing) two. Have always caught it on the second check, but then ya gotta get back in...

ETA - OK, I read this wrong after reading other responses. Disregard the newbie...

Yes.
The worst was finding 14 Vicoden in the drawer for Tylenol suppositories.
I notified pharmacy, wrote my manager, and filled out a report for the medication committee.
The next night it was still the same.
A pharmacy tech came to the unit and said, "All fixed."
But he had put suppositories in and left the Vicodin.
Three weeks later it was STILL the same. I filled out an incident report and sent it directly to the hospital attorney, wrote the Pharmacy Director, VP of nursing, and the CEO.

The next Monday night the Vicodin was still in that drawer!
I wrote a letter to the same people signed by all the RNs on our unit that WE would report this to the DHS if it was not fixed.

Tuesday night the Vicodin was gone and I had a "thank you" from the CEO in my mail slot.

Yes, Calcium Chloride was stocked in Calcium Bicarb drawer. Caught the switch in time. The pyxis is only as foolproof as the people who stock the pyxis.

Our Ativan and Morphine carpujects look exactly the same, down to the green cap. Found those switched more than once. And every so often the oral and IV formulations will get switched. The thing is that WE stock the Pyxis. The pharm tech brings down the narcs, we count and sign for them, and then restock the Pyxis. Of course, the Pyxis is in the area of the unit where the cardiac post-ops go, so it's inevitably one of the busiest nurses on the floor who has to restock the machine. Still no excuse, IMO.

I love what you said. That is exactly what I was thinking. You always have to check regardless.

That's why we are the humans and the Pyxis is a machine, made by, stocked by and used by us humans.

We need to be watchful and careful not just to protect our licenses but to protect our fellow human beings-our patients.

I found 10mg Coumadin tabs in the 81mg ASA drawer. Oops...

Yep, I have also seen empty morphine carpuject vials so make sure you guys are actually checking that fluid is in those puppies.