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

Nurses General Nursing

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  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?

Specializes in IMCU.

Found morphine vial in the percocet drawer. Just showed it to a coworker as a witness and pulled it out and gave it to the Charge Nurse and told him what happened. I don't know why that one vial was in there. We had just hired a load of new nurses. I suspect someone just got frustrated trying to do a return and put it in the drawer when they got percocet out, but I don't know.

Mahage

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Specializes in RN CRRN.
Yes, Calcium Chloride was stocked in Calcium Bicarb drawer. Caught the switch in time. The pyxis is only as foolproof as the people who stock the pyxis.

How come those that fill the Omni are pharm techs who need no witness to fill it? We take a med out and have to waste it with a witness. What stops one of them from pocketing a med and then blaming it on us? I mean it probably won't happen (or from an impaired nurse from blaming it on the tech if they divert?-They SHOULD have a witness---protects them and us I mean seriously@! ) We go to school for AT LEAST two years and they just get handed meds and are trusted to put them in and not get blamed if it is off?

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Specializes in Utilization Management.
How come those that fill the Omni are pharm techs who need no witness to fill it? We take a med out and have to waste it with a witness. What stops one of them from pocketing a med and then blaming it on us? I mean it probably won't happen (or from an impaired nurse from blaming it on the tech if they divert?-They SHOULD have a witness---protects them and us I mean seriously@! ) We go to school for AT LEAST two years and they just get handed meds and are trusted to put them in and not get blamed if it is off?

I don't think the tech could easily get away with diverting because the count would be off from the start. I believe they double-check with the Pharmacist, then deliver the meds.

I'm sure there's a way around the checks, but frankly, I have never heard of a nurse being the scapegoat of a diversion that had the source in the Pharmacy itself.

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Specializes in CTICU, Interventional Cardiology, CCU.

just had my first problem with this recently. I was pulled to another floor for the night. I have been on this floor many times before so I knew the nurses. I pulled my 10pm meds from the pyxis. I went to give my pt. 0.5mg of xanax and when I did the bedside check of the med before I administered the med I noticed I had a 0.25mg of xanax still in the pill pack. I always do multiple med checks before I administer the med. I said to the pt. I would be right back. Took all of the pills I had for 10pm meds still in their packaging and went back to the pyxis I pulled the med from. I logged in, brought up the pt and the meds. I saw the xanax 0.5mg on the screen profiled for the pt. it was the ONLY xanax order for the pt which I made sure and even checked the chart 2 times, I touched the xanax 0.5mg on the screen and the drawer opened, the cubie pops open and I pulled out what was susposed to be 0.5mg of xanax and checked ALL the pills. Yea there was an awesome mix of 0.5mg and 0.25mg of xanax in the same cubie.

Ok since this is NOT my regular floor, I made sure I checked what I was doing like 4 times. I said to the charge nurse there is a problem with one of your pyxis in the back. Now this floor has 3 pyxis machines. I showed her and 2 other nurses the med problem. I explained that I pulled a 0.25mg of xanax from the 0.5mg xanax cubie and showed the charge the ridiclous mix of 0.25and 0.5 xanax mixed in the same cubie. We went into the med log in the pyxis to see if someone retured xanax to the wrong drawer..NOPE. The last person before me to access that specific cubie was the pharmacy for med refill.

What a pain in the rear. We had to call the pharmacy and they had to come reconcille the problem. We had to check all 3 pyxis machines to make dure that the 0.5mg and 0.25 mg xanax were in the correct pockets in all 3 pyxis machines. Now this was well after shift change and narc counting that was done at 7pm. It must have happened when they did the med pocket refills around 8 or 9 pm. All 3 pyxis machines had the same problem with xanax, they were all mixed up. 0.5 and 0.25 were in the same cubie. The person who must have refilled them must have gotten the two dosage strenghts mixed up or wasn't paying attention. Even the nursing supervisor at night had to come and see what happened.

THANK GOD I ALWAYS double and triple check my meds before I administer them. The chrage nurse on that floor said to me..good catch Ang, I can tell your director that you discovered a major med. error b/c you are an observant and great nurse for catching something that could have been a major problem.

I said thanks, but also thought, I know sometimes we rush through med administritation b/c we may be be behind or just trying to give them on time, but how many of us just pull from the pyxis, assuming the machine is right and just give the med with out actually looking at the packging, or just give a glance at the packging, ok it's the right med, but don't really pay attention to the dose? We just assume that the med in the pocket that flipps open is the right med, or dosage?

One thing I have learned is always check and re-check your pt. meds no matter what.

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Specializes in LTC, MDS, ER.

Speaking as a former pharmacy tech, I think the biggest error I've ever come across happened when a *new* pharmacy tech was delivering narcotics to all the Pyxis machines. She got to the PACU and accidentally mixed up the fentanyl and sufentanil (sufentanil is 10 times more potent than fentanyl). The awesome nurses down there caught it and called us. When a pharmacist and I checked the computer to see if any had been taken out since it was restocked, we noticed an anesthesiologist had taken one for a patient.

Thank God he hadn't given it yet and we were able to get a hold of him...

Our hospital has a high turnover rate for pharmacy techs, and some of them don't have previous experience and/or their certification yet. I always double-check everything when I'm pulling meds for clinicals. I love the pharmacists and the techs, but the volume of drugs they're working with and the number of orders they fill on a daily basis is staggering.

My teacher always says nurses are patients' last defense...and I'd believe it! :)

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Specializes in Med Surg, ICU, Tele.

yep and discovered that this incorrect med had already been administered to the patient a couple times...

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Specializes in Cardiac/Med-surg/ LTC.

Yes & I'm sure I will in the future.

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Specializes in IMCU.

Yep, put in for percocet and drawer for morphine opened. Notified pharmacy. Next night, it did it again. Notified pharmacy.

Mahage

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Specializes in psych. rehab nursing, float pool.

God bless the Pixis. Not only have I found the wrong medication in the cubicles. I have found a wrong dose put in the cubicle. Pockets which show they have opened therefore the med was given, ah no the pocket did not open had to try try again.

No rest for the weary, always check the labels of the packages you are pulling name and dose. We have to remember humans fill the cubicles therefore are subject to error. Machines malfunction therefore are subject to error.

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Specializes in Cardiac.

Yes, and this is why I'm glad my hospital uses the 'scanner' method at the bedside. That's the extra red flag I need as a new nurse to help me not give the wrong med!

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Recently I have found 40mg tabs of Lasix mixed in with 20mg tabs and the exact same scenario with Lipitor. I addressed this with my supervisors, pharmacy, and other nurses to alert them. I pulled the med and pharmacy sent it back. They said to put it back and they would "fix it". yeah right. Handed it to the supervisor and filled out an incident report.

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