Medication Route Error

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I am a seasoned Nurse and feel so stupid for this issue...I worked a midnight recently and was to dose a patient with his Suboxone prior to transfer to another facility. I checked and double checked the dose ....I crushed the sublingual tab which is our practice. For some unknown reason I dissolved it in water prior to giving it to him . I know better...we dissolve our gabapentin in water prior to administration but never a SL Suboxone...oh I'm so upset! And I feel so dumb. I made my NA and the doctor aware. Now I'm extremely worried about the consequences.  I have extreme anxiety and can't stop going over and over it in my head

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Specializes in Vents, Telemetry, Home Care, Home infusion.

Per  FDA Suboxone medication guidelines: SUBOXONE sublingual tablets must be administered whole.   

Facilities practice of crushing med needs to be reviewed as contributed to this error.  Mixing with water might have increased absorption rate with increased risk of side effect, esp.headache.  Remember that saliva is a liquid too so crushing tablet + saliva may have similar rapid action.   

Thanks for being a contentious nurse.  Go easy on yourself --- lesson learned expect you will be  double checking med preparation going forward.    (HUG)

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OneRN50 said:

I am a seasoned Nurse and feel so stupid for this issue...I worked a midnight recently and was to dose a patient with his Suboxone prior to transfer to another facility. I checked and double checked the dose ....I crushed the sublingual tab which is our practice. For some unknown reason I dissolved it in water prior to giving it to him . I know better...we dissolve our gabapentin in water prior to administration but never a SL Suboxone...oh I'm so upset! And I feel so dumb. I made my NA and the doctor aware. Now I'm extremely worried about the consequences.  I have extreme anxiety and can't stop going over and over it in my head

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It is our orders to crush it....so that's in the doctor and facility and it doesn't absorb as well being swallowed...and could cause gastric upset and withdrawal symptoms due to not being all absorbed

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Specializes in Psych, Addictions, SOL (Student of Life).
OneRN50 said:

It is our orders to crush it....so that's in the doctor and facility and it doesn't absorb as well being swallowed...and could cause gastric upset and withdrawal symptoms due to not being all absorbed

That because it's not supposed to be swallowed but rather administered under the tounge.

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I know this ...I was replying to the other nurse who said it's not supposed to be crushed 

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Specializes in Psych, Addictions, SOL (Student of Life).
OneRN50 said:

I know this ...I was replying to the other nurse who said it's not supposed to be crushed 

Sorry - I was looking at a post that said the hospital policy was to crush because swallowing it would cause stomach upset

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I work in prison and the order is to crush for less chance of diversion....I gave the right med and right dose but I unintentionally added water....I don't know what I was thinking ...other than that's how we do our gabapentin and now I'm stressed out so much because I can't afford to lose my job

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Specializes in CRNA, Finally retired.
OneRN50 said:

I work in prison and the order is to crush for less chance of diversion....I gave the right med and right dose but I unintentionally added water....I don't know what I was thinking ...other than that's how we do our gabapentin and now I'm stressed out so much because I can't afford to lose my job

You are not going to lose your job!  You reacted ethically.  We all make errors.  It makes us more careful.  The moral of the story is that your can't let anyone or anything  distract you while pulling meds.  I'll bet most of us learned that the hard way:)

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Thank you for the reassurance...I'm stressed out to the point of tears...I offered to make out an error report.. I have notified my nurse administrator and the doctor

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Specializes in CRNA, Finally retired.
OneRN50 said:

Thank you for the reassurance...I'm stressed out to the point of tears...I offered to make out an error report.. I have notified my nurse administrator and the doctor

Have a good night's sleep and remember, this was a minor error and in a week it will rotate to the back burner.

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I hope it passes soon I hate this inner turmoil...I feel like I've done what I should by reporting to my supervisors and if they take it further I guess I'll have to go through it 

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Specializes in Psych, Addictions, SOL (Student of Life).
OneRN50 said:

I work in prison and the order is to crush for less chance of diversion....I gave the right med and right dose but I unintentionally added water....I don't know what I was thinking ...other than that's how we do our gabapentin and now I'm stressed out so much because I can't afford to lose my job

I don't know how it works in the Prison system but in general if a medication error causes no harm it should be dealt with as as an training and educational matter. It the case of this particular medicaton it needs to be given by the sublingual route to be effective. The bioavailability in the intestine has not be observed and it is most likely in effective at that route. 

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