Pyxis (almost) nightmares.  PLEASE be careful. Pyxis (almost) nightmares. PLEASE be careful. | allnurses

Pyxis (almost) nightmares. PLEASE be careful.

  1. 10 The Pyxis is a touchscreen, and we all know how sensitive touchscreens can be. Plus, there are many ways to go about pulling the med for the patient. Search by pt name, search by bed number, search by generic name, search by brand name, etc.

    I've always been extra careful with the Pyxis for that reason. At the top of the screen (in smaller letters than it should be, IMHO), it shows the name of the patient and the med that you are pulling. PLEASE look at it carefully!

    A few times when I was pulling, the wrong patient name came up because I must have touched the wrong name. Once I get to the med, the wrong med name has come up for the same reason.

    I was waiting in line with a co-worker, and she was pulling a narc. I just so happened to look at the screen right before she hit exit, and I realized she had pulled sux instead. (The patient had been intubated during the hospital stay, so it came up as a previously administered med, and she must have accidently hit that one.)

    I stopped her immediately, she looked at what she had in her hand, and she turned ashen. The bedside five rights may have stopped her before giving it to the patient, but we never know what our co-workers practice habits are, unfortunately.

    The Pyxis is convenient and it helps ensure correct billing. It has its flaws as the above story can attest.

    One time, however, it saved me and my coworker.

    At my place of employment, floats, registry, and agency do not have access to our Pyxis, so someone has to pull for them. I volunteered to pull a narc for a float recently. She told me the name of the narc, but I didn't look at the MAR she had in her hand (my mistake, from which I learned). When the list of previously administered meds for the patient came up, the narc she told me had never been pulled, but another one had. We rechecked the MAR, found that she misread the name, and we pulled the right one. She apologized profusely to me, but the important thing is we caught it.

    Just thought I would share as a lesson I learned from.
  2. 24 Comments so far...

  3. Visit  blondy2061h profile page
    2
    A lot of my patients, being a specialty area, are all on the same meds. I've gotten to like the 6th med I had to pull before realizing I was under the wrong name.
    redhead_NURSE98! and LPNnowRN like this.
  4. Visit  dudette10 profile page
    0
    Quote from blondy2061h
    A lot of my patients, being a specialty area, are all on the same meds. I've gotten to like the 6th med I had to pull before realizing I was under the wrong name.
    It's so easy to make a mistake with a Pyxis. Those screens are TOUCHY!
  5. Visit  nurseprnRN profile page
    1
    you can give this feedback to the pharmacy, who signs the contract for the pyxis, and they will pass it on, or you can contact pyxis directly and tell them.

    pyxis medication and supply management

    carefusion is committed to providing a positive customer experience. our experienced support representatives are well equipped to address your needs around the clock.

    pyxis technical support center
    tel: 800.727.6102
    QueenMangin likes this.
  6. Visit  dudette10 profile page
    1
    Thank you, Grn Tea. A relatively simple reprogram of the Pyxis could help. Once you choose a patient or a med, it could ask you to confirm pt or med in BIG LETTERS right in the middle of the screen. Having both at the top in small letters is a problem, IMO.
    Liddle Noodnik likes this.
  7. Visit  nurseprnRN profile page
    1
    tell 'em. it's always been my experience that manufacturers are pretty receptive to nursing feedback, assuming you're not doing something completely off the wall. this does sound like an easy fix to avoid a lot of problems, so they should be able to adjust the resolution on the screen or the letter size or add the confirmation in big letters, whatever is easiest.
    dudette10 likes this.
  8. Visit  tokmom profile page
    1
    Pyxis isn't foolproof, that's for sure! We have bedside scanning and I'm thankful for it!
    deleern likes this.
  9. Visit  Esme12 profile page
    2
    Machines are falliable the is why you must do the 5 "R's" prior to administration as you look at the patients arm band and MAR.
    deleern and VickyRN like this.
  10. Visit  Liddle Noodnik profile page
    1
    I like the idea of having to confirm, IN BIG LETTERS ... each person, each drug. maybe seems redundant but in this case redundant is GOOD!
    VickyRN likes this.
  11. Visit  CapeCodMermaid profile page
    2
    How big are the letters on the MAR? The pyxis is only a tool. And, just because we don't already have enough to think about, the 5 rights are now 7...the right to know what the medication is for and the right to refuse.
  12. Visit  OnlybyHisgraceRN profile page
    1
    Thank you. I almost did the same thing. Right patient, wrong medication. I was looking for something and accidently hit sux, thank goodness I caught myself before hitting the remove button.
    When ever I pull meds I always check the dose on the medication. Sometimes what the screen says it is is not it....
    dudette10 likes this.
  13. Visit  OnlybyHisgraceRN profile page
    0
    Quote from CapeCodMermaid
    How big are the letters on the MAR? The pyxis is only a tool. And, just because we don't already have enough to think about, the 5 rights are now 7...the right to know what the medication is for and the right to refuse.
    Right on!! My preceptors drills this in my head.
  14. Visit  subee profile page
    2
    Quote from dudette10
    The Pyxis is a touchscreen, and we all know how sensitive touchscreens can be. Plus, there are many ways to go about pulling the med for the patient. Search by pt name, search by bed number, search by generic name, search by brand name, etc.

    I've always been extra careful with the Pyxis for that reason. At the top of the screen (in smaller letters than it should be, IMHO), it shows the name of the patient and the med that you are pulling. PLEASE look at it carefully!

    A few times when I was pulling, the wrong patient name came up because I must have touched the wrong name. Once I get to the med, the wrong med name has come up for the same reason.

    I was waiting in line with a co-worker, and she was pulling a narc. I just so happened to look at the screen right before she hit exit, and I realized she had pulled sux instead. (The patient had been intubated during the hospital stay, so it came up as a previously administered med, and she must have accidently hit that one.)

    I stopped her immediately, she looked at what she had in her hand, and she turned ashen. The bedside five rights may have stopped her before giving it to the patient, but we never know what our co-workers practice habits are, unfortunately.

    The Pyxis is convenient and it helps ensure correct billing. It has its flaws as the above story can attest.

    One time, however, it saved me and my coworker.

    At my place of employment, floats, registry, and agency do not have access to our Pyxis, so someone has to pull for them. I volunteered to pull a narc for a float recently. She told me the name of the narc, but I didn't look at the MAR she had in hSuxer hand (my mistake, from which I learned). When the list of previously administered meds for the patient came up, the narc she told me had never been pulled, but another one had. We rechecked the MAR, found that she misread the name, and we pulled the right one. She apologized profusely to me, but the important thing is we caught it.

    Just thought I would share as a lesson I learned from.
    Sux does not belong in a pyxis. Wayyyyyy to dangerous ; plus it has to be kept refrigerated. To make this even a dumber move than it is, it's CHEAP.
    dudette10 and Anna Flaxis like this.

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