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

I pulled D5 from the NS compartment on our IV pyxis.

Yeah went to grab a bag of NS the other night, and it's a good thing I always check the labels because it was 0.45% NS.

Yes, but I didn't notice that it was Dilaudid that I'd pulled from the Morphine section. I was giving it slowly, and noticed my patient was getting way more stoned than I'd anticipated. I cut the dose short, and only after that discovered that the wrong med had been in the machine. That mistake helped pharmacy track a bunch of other errors to the same tech, who is no longer with us in that capacity.

Fortunately, it was at least a similar narc pain med, and I gave it slowly; so no real harm done. The possibilities scare me, though. Now, I check EVERYTHING coming out of that machine.

We have a little game called 'which med will be missing from the Pyxis tonight?'

I think the largest error potential are the drawers in the pyxus where all the cubicles are open when the drawer opens, it is very easy to put meds back in the wrong cubicle and that is where i have found the most errors.

Other then that our Morphine Sulfate and Hydromorphone syringes look identical, the only difference is the words printed on the label.

Thank goodness for all our checks. At the hospital where I work we are all computerized and scan the medications into the computer so it's sort of like an extra check. An error message will come up if it's too early, too late, wrong dose, med order not found, etc etc.

i have encountered many situations in which the wrong med was in the wrong drawer... i just look @ the little blinking lights * we have omnicell* same thing... i still call it a pyxis..cause thats what i was raised with... we have these really nifty heparin flushes...they are this yellow syringe... we often run out of them and there are some of the older vials in there... both 10mls.... we also have heparin boluses that are in the vials.. well... i was pulling up some *flush* heparin and noticed that it was indeed not a low dose flush but actual heparin....

i about wet myself cause i was so glad that i caught it because i was in such a hurry.. it can get crazy in an er... we all know that... but one must always.. ALWAYS double check the med you are drawing up or whatever....

oh.... and i want to make a real quick vent...

I HATE AMPULES!

why should we have to deal with rotating them so all the med is down there... then break off the top. *adds one more sharps hazard* then use a stupid filter needle to draw it up.. then change it back to a regular needle... or a blunt needle... my hospital has gone pretty much needlesess which took me a while to get used to but i really have grown to love the needleless system of stuff.... anyway....

I HATE AMPULES... i can do it in like a matter of seconds.... but just stick it in a vial!!!!

i told my sister about this... she works for a big pharmaceutical company in research and development.... you know what she told me?

*thats not my deal.... its probably a chemical thing.*

i told her... WELL YOUR JOB IS TO FIX IT!!!....

then she proceeded to tell me.... uhhh... you are my LITTLE brother.. nor do you write my paycheck..... now go on nurse.... if you want a job.. let me know... you can make real money here....

yup,... is that not horrible?.... fyi.. my sister was an RN in a burn unit for like 5 years... then got recruited to be a pharm rep... which she did... then 10 years later she is in research???

sorry... im venting....

but yeah... ALWAYS check those meds that you get out of a pyxis or omnicell.... ALWAYS!!!!

I can't even begin to count the number of times the wrong med has been in the wrong place. We spend at least an extra 30 minutes having to get meds together because we have to double check everything! We have a new pxyis system and it is causing more hassle than we ever anticipated. I also don't appreciate calling the pharmacy during off hours and being told to call the doctor to get a med changed to another form so they don't have to come in.

I remember a week ago I found some Dilantin in the cubbie with some senna. It takes me a while to pull my meds because I compare it with the screen and the med rec screen in our charting system. I usually let people go ahead of me if I don't need to give a med right away.

I can't even begin to count the number of times the wrong med has been in the wrong place. We spend at least an extra 30 minutes having to get meds together because we have to double check everything! We have a new pxyis system and it is causing more hassle than we ever anticipated. I also don't appreciate calling the pharmacy during off hours and being told to call the doctor to get a med changed to another form so they don't have to come in.

We have it happen often too, and you'd better believe if was nursing error related, the fur would fly so to speak.

We have even found narcotics in pocketc that already had non narcs in it, the whole 9 yds.

Anne, RNC

Yep - 3 times in just over a year as a nurse. MOM in the Maalox slot (stocked in neighboring cubbies - poor design). Was sent up a bag of meds labeled "compazine" on the outside, but the individual blister packs were actually Phenergan. Found 200mg theophylline in the 300mg cubie just last week. No problems with narcotics to date.

Pharmacists/Rx techs are mere mortals, too - that's why we are supposed to independently check the 5 R's. :)

Remember about 10-12 years ago when 30 mg high-dose epi vials were all over ACLS? We were working up an MI case when he arrested. Defib, 3 mg 1:1 epi, CPR, another shock. We decided to give 5 mg epi and as I was pulling up the dose, the syringe plunger wouldn't move. I looked down and realized I had a vial of Lasix. Instead of the epi, I had given him 60 mg of Lasix. The MD said not to worry about it, made no difference in outcome (only 3 minutes went by from when he should have gotten the 1st does of epi until when he actually got it--and the arrest was witnessed on the monitor so he was shocked within 30 seconds of deteriorating into v-fib).

But the big issue was: you've got two, rather large brown vials with orange-yellow tops setting next to each other in the drawer. We put a yellow sticker across the top (for urine) on the lasix.

maybe I'm lucky but I haven't seen any misplaced meds in a long, long time.

and nghtfltguy, I hear ya about ampules. If it's a cost thing, then the pharmaceuticals could make less commercials each year and afford to package their products more conveniently!!

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