Patient died from 8GMs of Dilantin

wow, 32 vials! that should have alerted the nurse alone.

IMy concern though is the pyxis system...Shouldnt it be able to identify when the dosage is incorrect for a particular pt? This is a computerized system.It should be able to block a nurse from getting in excess of the correct dose for a particular pt.

In my mind once the pharmacist profiles the correct dosage, once the maximum is taken out then the nurse shouldnt be able to get any more of the medication.

We are living in a computerized age and so we should maximise the use of these computer systems to minimize errors of this nature.

I guess it depends on how the pyxis dispenses the medication? Our pyxis opens the main drawer and/or container and if you want to, you can take out all the meds in the container once it is open. And you can go back for a second dose, if the pyxis inventory shows that there is still medication in there. Do other pyxis' only allow one dose at a time to be retrieved physically?

I feel terribly for the pt, family and nurse. This is a lesson to all nurses to stop being affraid to "Look Dumb" (better than being so). I always ask my fellow nurses about things, and I've been a nurse for more than 14 years. I question doctors too, and I talk to the pharmacy a lot. We see a lot of strange doses where I work, but clarification never goes out of style. I've even asked the pt what their normal dose of said medication is, sometimes they know, sometimes they don't.
Nurses should not be affraid to ask questions; which means nurses should not put each other down and make one another feel stupid therefore so they can freely ask such "Stupid" questions.

What happened to her knowledge learned in Materia Medica & most of all what happened to checking Doctor's order & checking before drawing, then before giving. What is happening to the Nursing Profession- it's very scary. As a patient, I still check what they are administering. Someone dropped the ball allowing this Nurse to Practice. Boston Blackie-Graduate of Diploma School of Nursing,1955.