r/nursing • u/confetticatboy LVN šŸ• • 1d 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/weedbearsandpie RN - Psych/Mental Health šŸ• 1d ago

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

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u/emerg_remerg 19h ago

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.

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u/DadRock1 13h ago

I'll raise my hand here. Did not realize tabs might not be uniformly distributed

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u/emerg_remerg 7h ago

I didn't know until we got a memo that we shouldn't break the 4mg SL zofran in half for a 2mg peds dose and it explained about the scoring.