Mistakes

No harm came to a patient. You realized you pulled two accidentally. They were both in the return drawer. You emailed your manager and explained the circumstances. I don't think you will hear about this again. Too bad that the Pyxis person who was *on call* had to come in and fix something. I'm sure you were polite and professional. I'm sorry that the other person was not. Healthcare is 24/7 and not just for nursing.

i think you will be fine. Maybe a soft slap on the wrist saying to be more careful next time. At worst you inconvenienced someone - but no one got hurt and you didn't divert the meds. Don't stress over it.

oh geez! That's nothing!! I've done worse!! To make a long story short, I had a patient coding, a crush open heart arriving, I was pregnant, and really really sick!! My pt coded all day!! A Fentanyl gtt was ordered, it came up, I set it on the counter...it was not my priority, cuz the pt kept coding! By the time I got a chance to hang it, I couldn't find it!!! A whole bag missing!! I had to call pharm, explain the situation. They offered to cover for me, but I was not comfortable with that!! What if it ended up getting found and traced back to me?!?! So I wrote myself up!! They questioned me about it, and that was it...no harm no foul! You'll be fine! You owned up to your mistake, and documented. No big deal. When they do audits, and you hear about firings, it is usually bc of patterns that they are seeing!!

Our Pyxis makes us count ALL the meds, and they all come on rolls of pills, not those neat little sheets of ten that make them easy to count. I've had times I've taken every pill in the drawer out to count and accidentally shut the drawer leaving none in there.

I can't remember what I did as it was awhile ago, I think the one of the drawers that spins got stuck. It ended up this big mess because it kept wanting me to count all of the meds in the drawer with a witness, but I couldn't because it was broken. Thankfully one of the pharmacists was on the floor and came over to fix it. She ended up having to count the entire pyxis of meds. We were like, well, at least three of us were involved, surely they won't fire us all if something comes back miss counted.

Our Pyxes also gave us like 10 seconds to get out insulin. It usually took longer than that just to find the correct vile as nobody seemed to put them back in the correct spot in the fridge. I would get errored out almost every time.

I also lost a vicodin once for about 15 minutes. I was a brand new nurse. I walked into the room with my hand full of the patients meds for dinner time, including a couple of syringes and a bunch of packages of pills.

Well, some how when I threw an empty package away I also threw away the unopened vicodin along with it. I realized it was missing right away, and looked around for it. After not finding it I went into my managers office and was like "Um, what happens if I lose a vicodin??"

She jumped up and we both went searching and covering my tracks following where I went from the time I took it out of the Pyxis to the pt's bedside. I had already looked in the trash, but didn't see it. I looked one more time and there it was stuck to another package. Thank goodness!

I think since they recovered the 2 pills from the return drawer you'll be fine.

NO HARM! NO FOUL!

It is times like these I miss the cabinet with the keys and the paper log!!

I've done this a zillion times. I even ended up with an entire card of Vicodin once. You just get moving so fast sometimes, it's easy to do.

Here is what I do.

I go back in like I want to remove another of the same med. It will ask me if I intend to give the full dose, etc., and I punch in "accept".

I go through the whole process until the pocket is open, put the extra pill(s) back in the pocket, then "cancel" the med.

It will instruct me to leave all the meds in the pocket and close it.

This way you don't have to return or waste or anything, and your count should still be correct, because when you initially counted and accidentally removed two pills while telling the Pyxis you were removing one, it accounted for the one. Make sense?

I've not only done this mistake, but I've gone to the Pyxis for one patient, grabbed something like morphine, but accidentally took it out under my other patient's name. What a pain in the orifice that was! I mean, the right patient got the drug, but it was dispensed under the wrong name. It was painful trying to fix that in the Pyxis!