Dr. Kati Forbes, PharmD, RPh
Region: US
Wednesday 19 August 2026 23:14:08 GMT
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vanderspikesrules :
Don’t rush us 👏
2026-08-21 12:14:24
203
Daniel :
As a clinical pharmacist, these are the horror stories I hope to not be
2026-08-20 00:28:40
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✵.｡.✰ 𝓚𝓲𝓻𝓪 ✰.｡.✵ :
as an IV tech and pharmacy student, I just don't understand how. at least with our hospital, we can't make anything without a label and scanning each product. the pharmacist is supposed to verify the drugs and fluids as well, before and after making! also, none of our potassium and bupivicane, even from the same manufacturer, look anything alike. this feels like a bigger issue in that hospital
2026-08-20 06:19:39
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RikiTikiTeak🧂 :
OK, but with Ascension, I’m not surprised
2026-08-20 00:11:59
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Paige K :
but the vials have no similarities to bupivicaine... maybe lido, bit not potassium to bupivicaine.. None of the Potassiums come on glass vials, except maybe potassium acetate..
2026-08-20 02:31:56
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Nicole :
My guess is someone drew up the drugs and didn’t immediately label them.
2026-08-20 01:36:23
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BS :
Spot on. And for some anesthesia-specific context, normally for spinals for knee replacements we use bupivucaine from the spinal kits. But one of the largest factories worldwide had a recall recently for meningitis risks. I’m guessing their workaround was to have pharmacy compound or draw from a multi-dose vial in a sterile manner. Very sad and sobering.
2026-08-19 23:27:16
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renegadesquash :
My jaw was on the floor, like are we absolutely dead-ass right now? How on Earth does that even happen? Is potassium not stored securely in hospital settings and with warning labels galore?
2026-08-20 02:09:57
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S :
This is what truly scares me about being a healthcare worker now. We’re all being forced to constantly hurry up and get faster while also maintaining absolute perfect documentation, practice, and patient care, and it’s genuinely just impossible without the risk of sentinel events ballooning.
2026-08-20 01:21:52
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daniela :
as a hospital pharm tech i am speechless. If they are dispense prepping/scanning, why would it let them override the wrong medication? potassium and bupi vials look nothing alike, at least the products that we use look nothing alike. only thing i could think of was that they were compounding multiple items at the same time and labeled the wrong one
2026-08-20 10:54:01
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Meg :
I said “oh shit” out loud when I heard her say potassium 😬😳
2026-08-20 16:46:13
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Wkc96 :
In addition to the scanning and pharmacists final check we have a camera in our iv hood to take pictures of all of our ingredients
2026-08-21 00:06:41
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Thermo :
Honestly - I’m surprised they’re using an epidural for a TKA. Haven’t done that in years. My facility just does a PNB.
2026-08-20 05:37:03
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𝒮𝓌ℯℯ𝓉𝒥𝒶𝓈𝓂𝒾𝓃ℯ𝒯ℯ𝒶 :
TCT here in NE we aren’t allowed to check compounded meds, only a pharmacist can. There’s also cameras in the hood taking pics and recording the process and they have to scan it into Epic as well as keeping the vials used to check everything. This is one of my worst fears as a hospital pharm tech, and why I double check everything I send out.
2026-08-21 11:20:47
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Auhsoj :
I never want to be in their shoes; I’ll pray for them
2026-08-20 01:21:42
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Erica Stevens :
I’m sure whoever made the mistake feels absolutely horrible too. Hope they have the support they need too.
2026-08-19 23:38:28
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Cara :
If it doesn’t scan I have someone else look at it to see if it is wrong or not in our system yet. This is scary to hear. I scan every drug everytime
2026-08-21 16:09:18
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Kmart :
My thoughts on this— what the actual hell
2026-08-19 23:24:10
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Dr. Kati Forbes, PharmD, RPh :
*Correction: It was a spinal not an epidural
2026-08-29 09:45:29
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E=MC2 :
is the pharmacist going to be criminally charged like nurses are?
2026-08-20 07:38:41
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Suzanne :
Tennessee does not allow tech to tech verification
2026-08-20 18:31:36
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MiaTia :
I am so very confused because when they talked to our hospital about it, *which is in an entirely different state & unaffiliated* — they said that it was pre drawn up where they did the actual procedure and that the wrong drug was in the right spot of the Pyxis..Which will be normal because most ORs or any other operating places they draw their own stuff. We deliver it in vials. But now they’re saying it was drawn up in the pharmacy and delivered? This is why the hospital needs to make an actual statement. Because now certain news outlets are putting it on pharmacy when it was originally reported it was put on anesthesia. If it was pharmacy, and if it was a pharmacy technician, this just goes to show how serious our job is. Yet the people are so underpaid and overworked.
2026-08-21 09:22:22
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Melissa QT :
Omg this is absolutely horrendous and I can’t imagine this for the patients and families. Prayers for the victims and families!
2026-08-21 04:39:04
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Meena Quyyumi :
What is in the joint solution or was it in a syringe? Potassium is not usually stocked in the AWS.
2026-08-21 02:23:49
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lehighk2000 :
Or…it could have been the tech that was compounding had multiple orders in the hood. Which is why I only do 1 order at a time.
2026-08-22 10:57:47
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