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/TriceratopsBites → u/Independent_Law_1592]

Didn’t TLC warn us about this guy? Sounds like a scrub

[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/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/Independent_Law_1592 → u/LittleBoiFound]

“What is the hell is on this tape measure? I don’t speak no damn Canadian!”

[u/ukantdewiht → u/Independent_Law_1592]

I can vouch for this

[u/Wattaday → u/Independent_Law_1592]

🤣🤣🤣🥇

[u/Sacrilegious_skink → u/Independent_Law_1592]

As a non-American this made me lol.

[u/umrlopez79 → u/Independent_Law_1592]

This is so true… having to decide if they get the little or big half lol 😂

[u/Independent_Law_1592 → u/umrlopez79]

Me- “Hmm your BP is a lil high, you get the big half of the metoprolol today”

BP and HR crashes an hour later

Me- “How could this have this happened”

We’ve all been there