My interesting clinical day

  1. This morning I was taking care of a very sweet patient. My morning was going very smoothly... my assessment was done early, my charting was done early, I knew all the meds I was giving... it was super. I had one 8:00 med to give, but when I went into the med room, it wasn't in his drawer (it was a pretty new order, though, so I wasn't that surprised). There was only one PRN med, and his 10:00 SQ injection (which I was really excited to give because it'd be my first injection ever.) I told the nurse the 8:00 med was not there, who called the pharmacy and said they would bring it up shortly.

    A while later the pharmacy tech came up and started to unload the medications. I managed to find the 8:00 med to give and gave it. When I came back later to pull my 10:00 meds and opened his drawer, I was amazed. There must have been at least 50 medications in his drawer (he was prescribed about 8, total). A few were drugs that should actually be in Pyxis, and many, many were drugs he's not even taking. I told my instructor and the nurse, and the nurse and I went through the chart looking for new orders, went through the MAR looking for updates, but indeed, none of the meds were his. I pulled out every drug individually, checked it against my med list, but was unable to find ANY of his 10:00 meds, INCLUDING the SC injection that WAS in the drawer an hour and a half earlier (which still bothers me... where did it go???)

    Then my classmates went in to pull their 10:00 meds and all their drawers were empty. Their nurses also called the pharmacy, and it turns out the prescription robot that sorts the medications for delivery (to alleviate med errors) had seriously malfunctioned. So when I left the floor at 11, no one was able to give their 10:00 meds.

    I was pretty proud of myself for realizing something was seriously amiss (although with a drawer full of 50+ medications, I'm not sure I could have missed it if I tried) and for contacting the nurse and my instructor to try and get to the bottom of it. The bad news is I didn't get to give my injection, but I know I'll get another chance.
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  2. 7 Comments

  3. by   moongirl
    good catch!!!!!!!!!!!!!!!!!!!
  4. by   Lisa CCU RN
    Is it just me or shouldn't the tech have realized something was wrong when they put 50 meds in one person's drawer and zero in the others? And what did happen to the SQ injection?
  5. by   Megsd
    Quote from CRNASOMEDAY25
    Is it just me or shouldn't the tech have realized something was wrong when they put 50 meds in one person's drawer and zero in the others? And what did happen to the SQ injection?
    One would think... I know if *I* were that tech I would seriously question that amount of meds for one person, especially if I looked at which meds they were.

    And I don't know what happened to the injection. All I could do was report to my instructor and the nurse that it WAS in there earlier and was gone. I don't know enough about how the pharmacy works to know, but the only logical explanation *I* can think of is if the tech comes up to the unit with a list of what meds should be in the pt's drawer and if they see any that don't belong, they take them out. If the list was messed up (and listed all the meds he's not on -- the ones she put in the drawer -- and not the ones he is on) maybe they took the injection out since it was not on the list and took it back to pharmacy.

    Your guess is as good as mine.
  6. by   smk1
    good save!
  7. by   EricJRN
    Good job!
  8. by   firstaiddave907
    yes very good save.
  9. by   AuntieRN
    Good job...you should be proud of yourself.

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