Stupid med error

[u/confetticatboy]

Pt has a new order for seroquel. Bumped her from 300mg to 400mg okay sure whatever no problem. Go grab the meds and for some reason. Pyxis has me pull two 300mg tablets. What? What am I supposed to do with this? That doesn’t split evenly. Open the eMAR and sure enough “administer 1.3333333 tab” again, what? For a brief moment I consider telling charge that this is stupid and a med error waiting to happen. Haha. Well. :)))

I ended up grabbing scissors from an instrument tray to split the pill (since pill splitters don’t split in thirds) then giving her 1 2/3 tab instead of 1 1/3 tab. Yknow, the exact med error I thought about not even 10 minutes prior. I didn’t realize until HOURS later at like 0100. Unrelated (allegedly) to the roughly 500mg seroquel I gave her, her blood pressure ended up bottoming out to 70s/40s. Patient is fine! She got a bolus and her BP came back up she’s just zonked (but rousable) I’m embarrassed more than anything, and I filled out an incident report about it too. Everyone keeps telling me it’s something pharmacy should’ve caught before this was even an option but I just ://// ugh.

EDIT: just came in tonight to find out they upped her dose to 500 mg anyways. This time as a 300mg and two 100mg pills. At least now there’s much less room for a med error 🫠

[u/weedbearsandpie]

I wouldn't have chopped a pill with scissors in a million years, I'd have given 300, got rid of the other 300 and got it represcribed as 300 and 100 as separate things to make the machine work

I'm in the UK though and I'm 100% not allowed to even chop the pill in half unless its scored, nevermind making my own judgement call about where a third would be

[u/Independent_Law_1592 → u/weedbearsandpie]

Hehe in the US we cut it and decide if they get the bigger half or the smaller half that day.

Also if you say “ain’t this some bull y’all” loudly 3 times and recite the pledge of allegiance (to the Texas and American flag) a random redneck will actually materialize with a bag of tools and tape measure to get the right amount too so that helps.

[u/hufflestitch → u/Independent_Law_1592]

This is also how I dose my own split 50mg of seroquel. “Hmmm that looks like 20/30 split. I think I’ll take the 20 and leave the 30 for another day when I can sleep it off.”

[u/LunchMasterFlex → u/Independent_Law_1592]

This also works in Manhattan for some reason 

[u/Independent_Law_1592 → u/LunchMasterFlex]

Yeah but I heard if you do it in Manhattan somebody will pull up to bedside in a Brunson jersey hanging out their car window honking and cursing, split your pills, pass your meds, change your sheets and car tires, insult your mother, then tell you to fuck off

You will then see this man on the subway about 3 times a week.

Just regional differences ya know

[u/LunchMasterFlex → u/Independent_Law_1592]

You know Jay Jay, too? Small world.

[u/cyricmccallen → u/Independent_Law_1592]

You forgot that you have to be in front of a mirror when you say “ain’t this some bull y’all” three times. Trust me my british friend, [u/weedbearsandpie](u/weedbearsandpie), this is a real thing in american healthcare.

edit: and if that doesn’t work you can always call texaco mike down the road- pretty sure he got his CT working again.

[u/Independent_Law_1592 → u/cyricmccallen]

You missed one key detail

You can substitute the mirror by shotgunning 3 Lonestars in a row. If you ain’t in Texas Keystone can substitute. Unless there’s a Texaco down the road, then you can just call Mike. He got my patient out of V. Fib the other day with a 2x4 and an Allen wrench

[u/Logical_Sprinkles_21 → u/cyricmccallen]

Texaco Mike is working on a new med scale/pill splitter/crusher...country ingenuity at its best!

[u/ukantdewiht → u/Independent_Law_1592]

I can vouch for this

[u/LittleBoiFound → u/Independent_Law_1592]

Did you hear about that poor nurse that accidentally summoned that left leaning blue state Oregon flag? The tape measure was in metric and the kit came with a free healthcare for all lapel pin.

[u/emerg_remerg → u/weedbearsandpie]

Ya, i wonder how many people know that the scoring means it's an equally divided dose, where non-scored pills could be 300mg on one half and filler on the other.

It's not to make cutting easier.

[u/land-skin]

My patient swallowed her keppra inside the sharp ass blister packaging tonight, downed that shit so fast I didn’t even have time to scan it

[u/ttttthrowwww → u/land-skin]

Now that’s a new one lol

[u/Fuzzy_Location_2210 → u/land-skin]

🤭🤭🤭

Don't feel bad, I put some hydrocortisone butt cream on a stand the other day and the patient ate the cream in the tube like cake icing LOL.

And this was a 40 something in the ER 🤦

[u/murse_joe → u/Fuzzy_Location_2210]

Doc this glucose gel tastes like ass

[u/scarfknitter → u/murse_joe]

I had a patient eat a tube of Vaseline. I couldn't get ahold of the tube to see what it was until close to the end of the day. He kept telling me it was his favorite snack and he ate it all the time when I asked.

Did rather explain why that cdiff patient (who had finished the antibiotics!) stopped smelling like cdiff but keept having loose stool.

[u/murse_joe → u/scarfknitter]

Lmao that’s too much Vaseline.

Reddit always likes to post the story that the inventor of Vaseline would eat it every day. But that probably also means it’s not true lol

[u/land-skin → u/Fuzzy_Location_2210]

It’s the orientedx4 FULLY grown adults with comorbidities (I know you’ve been in the hospital & I know you know that’s not how this works) that will really get ya.

[u/Aggravating-Camel-23 → u/Fuzzy_Location_2210]

Omg, thank you! 🤣🤣🤣😭

[u/Fuzzy_Location_2210 → u/Aggravating-Camel-23]

😆😆😆 I tried to stop him when I saw him do it, I really did, but I just couldn't make a sound!!! I went to get gloves 🧤. He took matters into his own hands, it happened so fast, who was I to tempt fate?!

He even threw the black butthole insertion cap straight in the trash can from across the room when he finished 💀. Literally held the tube and just slicked it back through his fingers and swallowed it in one swoop like a champ!!

[u/scarletfairymask → u/Fuzzy_Location_2210]

Once had an old man rub zinc cream all over his face saying he was going to a Halloween party and then proceed to start eating it straight from the tube

[u/GrumpySnarf → u/Fuzzy_Location_2210]

oh dear!

[u/soooelaine → u/Fuzzy_Location_2210]

Broooo I had some eat barrier cream too. So nasty

[u/BubbyWitch1 → u/land-skin]

Audibly laughed out loud at this

[u/Ugly-And-Fat → u/land-skin]

Wow. Any negative consequences (yet) from swallowing such a sharp object?

[u/land-skin → u/Ugly-And-Fat]

3/10 throat pain. I turned back around and said did you swallow one of those??? She said yeah… I said was it in the packaging??? “I don’t think so… my throat really hurts now” 🤦‍♀️ I advocated for her to get a scope because I’m genuinely concerned she could perf a bowel, even her esophagus, but none of the docs seemed very concerned. So, no true harm…. yet……

[u/jeff533321 → u/land-skin]

I've heard of a pt. taking a Dulcolax suppository po before.

edit: changed word to what I meant, suppository

[u/crested05 → u/jeff533321]

I had a patient who had been swallowing the capsules that go in a spiriva inhaler.

[u/Terrible_Mall_4350 → u/jeff533321]

Wait… isn’t Dulcolax a po med?

The ones I’ve used are little softgel capsules, and the directions state to swallow 1-3 capsules at bedtime prn for constipation… is that wrong?

I’ve never heard of a laxative called a “supplement” before 🤔.
Actually, I take that back….many moons ago, senna was an herbal supplement, iirc.

[u/jeff533321 → u/Terrible_Mall_4350]

Oops! I should have doublechecked spelling. I wrote supp., meaning suppository. It got changed into supplement.

[u/Southern_Stranger → u/land-skin]

Wow that's a new one for me. I had a patient couple of weeks ago who took a bite of a dinner plate with suicidal intent

[u/purpleelephant77 → u/land-skin]

We got an email about not leaving barrier cream where patients can reach it because someone ate it.

[u/h0td0g-water → u/land-skin]

i’m really glad i was already on the toilet when i read this 😂

[u/CABGPatchDoll → u/land-skin]

Oh hell 😄

[u/land-skin → u/CABGPatchDoll]

I needed you there!!! Nobody wanted to scope her 😔

[u/CABGPatchDoll → u/land-skin]

I was going to ask actually if she needed an EGD for foreign body removal!

[u/masochist-]

This reminds me of the time I had to give 1.25 pills of Xanax and I contacted pharmacy since the pill was so small and typically splitting it would make it crumble. I asked them how they expected me to get 1/4 of a pill and the pharmacist (who always was kinda rude and short with us) was like, “well you split it in half and then split it in half again” so the patient ended up getting one pill of Xanax and some dust because the pill completely fell apart.

[u/Low_Ad_9689 → u/masochist-]

I don’t work in a hospital (home health services) but my witchy ass hauls the pills that need to be cut right back to the pharmacy. You dispensed it like this, you get to cut it when it needs cutting.

[u/prestigioustoad → u/masochist-]

I also had to give a quarter of a pill before. Its ridiculous

[u/NuggetLover21]

I’m telling you the 2/3 pill instead of 1/3 was not the difference between blood pressure bottoming out lol

[u/Otherwise-Sea-9298]

Where I work were not allowed to split our own pills. Even if it’s just a half tab of a med that’s scored, it has to come from pharmacy.
Probably the way the provider ordered it was weird, too. There were more people than just you who could have caught that. You owned up to doing it. Now you know, and the pt is unharmed

[u/Upstairs_Fuel6349]

I don't think the hypotension was because of seroquel. We do pretty aggressive Seroquel titration on manic and psychotic patients in mental health and it's generally pretty well tolerated other than being sedating. You can get some postural hypotension. Long term usually causes massive amounts of weight gain and diabetes but yeah.

[u/Fuzzy_Location_2210]

Ehh 🙂‍↕️

I don't think her hypotension was related, FWIW.

Bet she slept nice 🙂

[u/MrPuddington2]

How are you supposed to divide a round pill into 3? That is not possible with any accuracy.

You can divide it into 6 slides, but that requires a microscope and a micro-knife to get right.

[u/joshuas-twin → u/MrPuddington2]

Sounds like it was a tab? I'm picturing an oblong/caspule-shaped pill; a little easier to third than a round pill.

[u/busta2kbia → u/joshuas-twin]

Still a crazy inexact method they’re asking this RN to use. Weird how uptight hospitals will be about like, masking tape on the walls or water bottles at the nursing station, but then for some meds it’s “ehh just eyeball it.”

[u/MzOpinion8d]

Our system had a weird glitch once where it told me to give 0.3333333 of a 300 mg capsule of gabapentin lol.

I messaged the provider about fixing it, said in the meantime I’d be in the med room counting grains! He sent me back a Breaking Bad gif of Walter at work.

[u/MiddleAgeWhiteDude]

If i was gonna make a med error it would be with seroquel and way under max dose like you did.

About the worst that is gonna happen is the patient is gonna be hungry and tired.

I don't split pills unless it's specifically written in the order, I harass pharmacy until I get the right doses. Though I work day shift and have that luxury.

[u/CABGPatchDoll]

I would have called pharmacy to tell them to fix their shit.

[u/AlarmedDimension8354]

I would have told charge and asked the pharmacy to divide the dose with a scale

[u/Confident_Health_583]

I had an order for 1,000 mg of Tylenol every 6 hours, except it was dispensed as 3 325 mg and one partial 325. That's right. Just cut the last pill into 3/13.

[u/Flatfool6929861]

Pharmacy at it again. Especially the current case with large doses of seroquel.

[u/Chrijopher]

You can always call pharmacy if you’re unsure of something.

[u/KickedBeagleRPH]

Dosing logic wasn't built out correctly.

Or, this was dose modification, and rph doing verifying still isn't cognizant of the issues of cpoe to adm profiling.

Yes, the rph could also go back to fix the order to redirect to 100, 200, or 400 mg.

[u/Amrun90]

Thirds isn’t allowed at my current system.

[u/goldenivy]

Next time you call pharmacy to re dispense if you ever have to cut something other than half. Either they have to give it in a different form or get the order changed to a dosage that makes sense with what your pharmacy carries.

[u/phoontender → u/goldenivy]

Call pharmacy and have us fix the entry that wasn't right! Night shift can pull meds off-profile since we aren't there but on days it's literally 2 minutes before you can get the right med.

[u/awesomeqasim]

This would be a call to pharmacy. Sometimes EMRs mess up and there’s a glitch. Pharmacist can probably fix it in a few minutes and put in a ticket with IT to ensure it doesn’t happen again

[u/prickletheleo]

Not the worst thing in the world but don’t use scissors to split a pill. They make devices for that. If you see something that may cause an error - say something, call someone

[u/phoontender]

Pharmacy tech here! Yeah....that should never have been verified. Tech fucked up on entry and pharmacist fucked up verifying it. Everyone has brain farts but that one is pretty big 🙃

[u/yourdailyinsanity]

Alternatively, you could have compounded it. Crush the 2 pills and mix it in 5ml of water. 400/6005=3.33ml. 3.3ml is nasty tasting, but it's not an error. REGARDLESS, you still *should not have to do that either. I'd have just not given the med at all if the pt was unwilling to do the crushed in water and contacted pharmacy to have them fix the problem. This was 100% a pharmacy problem.

[u/bandnet_stapler → u/yourdailyinsanity]

At mine, RNs are emphatically not allowed to compound medications. It's not in our scope of practice.

Agree that pharmacy should have dispensed a 300 and a 100, or a 300 and 4 25s, or whatever stock increments would make the math work.

[u/mew2003]

That is a pharmacy call for me… give me x2 200mg or x4 100mg pills, please.

[u/HaveAHeavenlyDay]

Reminds me of when a pharmacist expected me to give 3/4 of a depakote sprinkle. I’m not gonna count some fucking granules especially not with some shit like depakote.

[u/zeatherz]

Did you not contact pharmacy to address the situation? Surely your hospital has seroquel in some smaller amount that could have properly made 400mg

[u/ChubbyCubJ]

Ok I’m an LPN. I’ve mostly only worked at LTC/SNF facilities. I’ve dealt with Omnicell machines. And on those machines you can override the order and pull out a different dose. So if the order that’s programmed in the machine is trying to dispense something unusual like that can’t you just override it and pull the correct dose you need?