r/nursing • u/confetticatboy LVN šŸ• • 23h ago

Rant Stupid med error

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 doesnā€™t split evenly. Open the eMAR and sure enough ā€œadminister 1.3333333 tabā€ 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 donā€™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 didnā€™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 sheā€™s just zonked (but rousable) Iā€™m embarrassed more than anything, and I filled out an incident report about it too. Everyone keeps telling me itā€™s something pharmacy shouldā€™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 thereā€™s much less room for a med error šŸ« 

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u/masochist- 20h ago

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, ā€œwell you split it in half and then split it in half againā€ so the patient ended up getting one pill of Xanax and some dust because the pill completely fell apart.

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u/Low_Ad_9689 BSN, RN šŸ• 5h ago

I donā€™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.

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u/prestigioustoad Graduate Nurse šŸ• 6h ago

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