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

Nurses General Nursing

Published

  1. Ever find the wrong med or wrong dose of a med in the dispensing machine?

    • 226
      Yes
    • 42
      No
    • 4
      Other (please explain)

272 members have participated

For those of you who use a machine to dispense medications, have you ever discovered the wrong med or wrong dose of a med in the machine?

Once the whole cubbie was wrong. The tech got mixed up and put wrong meds in opposite drawers. We filed incident reports, transferred meds to right spots after having supervisor over-ride Pyxis, and then we were called on the carpet. Seems we should have had a new cart delivered and let the pharmacy fix the mess. Well, it was at night, no pharmacy, and patients needed their meds. Boy, some times you just can't please administration. Seems to me administration should have been jumping for joy that we did not give patients wrong meds and had a bunch of reports, not to mention doctors, patients and patient families to deal with. LOL!

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Specializes in Breast Cancer, Arterial, General Surgery.
Once the whole cubbie was wrong. The tech got mixed up and put wrong meds in opposite drawers. We filed incident reports, transferred meds to right spots after having supervisor over-ride Pyxis, and then we were called on the carpet. Seems we should have had a new cart delivered and let the pharmacy fix the mess. Well, it was at night, no pharmacy, and patients needed their meds. Boy, some times you just can't please administration. Seems to me administration should have been jumping for joy that we did not give patients wrong meds and had a bunch of reports, not to mention doctors, patients and patient families to deal with. LOL!

Damned if you do and damned if you don't!

All we have is general medicine trolleys with the patient having medicines that are specific to them.

We have found the occasional wrongly dispensed medicine.

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Specializes in Peds; Peds Oncology.

Wrong meds...have caught that.

Lots of wrong IVF in the wrong spot.

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Specializes in Med/Surg.

Yes, several times and that is why I remember the 5 R's. Besides we scan our meds to the patient armbands so it's not an issue.

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Specializes in Psychiatric.

Found 10mg Morphine carpujets in the 2mg slot..

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Renal med in the tylenol drawer - or something like that - Was definitely different than supposed to be.....

Scarey.

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Specializes in med-surg 5 years geriatrics 12 years.

I learned to really watch my IV drugs too. Once had a label on fluid saying Ampicillin, the little bottle attached said Augmentin. Good thing I didn't just activate and hang. I've always double and triple checked myself and that's a good reason why.

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ohhhh - I do that too on the IVPB that you have to mix, just to make sure the right med is on the bag!

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Specializes in Neuro/Med-Surg/Oncology.

Potassium

The 10 mEq and 20mEq bags were in each other's slots. :eek:

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EEk!!!

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Specializes in OR, PACU, Dialysis.

Often enough. What I love is when you contact Pharmacy the response you get is " Thanks for following the 5 R's". That's Special

My response is something like... I know the 5 R's, can your team read?

What really gets my goat is when I have to call Pharmacy and tell them we are out of a medication. The system has a par level and it should be set.

Why do we (the nurses) have to do everyones work?

:eek:

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Specializes in med surg.

ok if we pulled the wrong medication from the pyxis , arent we supposed to scan the barcode and check if we have pulled the right medication?

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