December 07, 2009 | | Comments 0
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An access code does not always guarantee medication safety

The next time you open a Pyxis machine in your organization, you may want to think twice about the contents of the syringe. Trinidad Smith, 28, a New Hampshire registered nurse, has pleaded guilty to tampering with the machine’s contents for her own personal use. Using a personalized access code to open the machine, Smith took syringes and vials containing Demerol and Dilaudid for her own use. Once Smith was finished using the drugs, she then filled the syringes with saline and returned them back to the Pyxis machine.

The investigation found 24 syringes and three vials that Smith tampered with. A further examination of the tamper resistant seals on the syringes revealed tape was placed over the cut or broken seals. The Forensic Chemistry Center of the Food and Drug Administration also found traces of the active ingredient in Benadryl in two of the syringes Smith tampered with. Further processing of the Demerol syringes found the medication to be diluted by approximately 46% to 85%, while Dilaudid syringes had been diluted by approximately 48% to 92%

Smith’s sentence is set to take place on March 8, 2010, and if the court accepts her plea agreement, faces an incarceration term of 15 to 48 months.


What are some processes your facility has in place to prevent this from happening? How can you ensure this from not happening in your facility? Do you think incidents like this affect the nursing image?


Source: US Department of Justice


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Sarah Kearns About the Author: Sarah is an Editorial Assistant in the patient safety group at HCPro, Inc. She contributes to two monthly newsletters; Briefings on the Joint Commission and Briefings on Patient Safety, and manages four e-zines; Accreditation Connection, AHAP Staff Challenge, Nurse Manager Weekly, and Healthcare Training Weekly. She also helps research new products for the patient safety and nursing market. She graduated from the University of Connecticut in 2008 where she earned her bachelor's degree in English.

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