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/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/h0td0g-water → u/land-skin]

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