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.