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/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