Best Catch Award

This edition’s Best Catch Award recipient is Nelson Towriss. Nelson was working on an inpatient medicine ward when fentaNYL 100 mcg x 1 prior to chest tube insertion was ordered. As fentaNYL IV was not commonly used on this ward, nursing staff misunderstood that the doctor had intended this dose to be given IV, and overrode a fentanyl patch out of their Pyxis machine (an automated dispensing cabinet). The physician then placed the transdermal patch on the patient prior to the procedure. Nelson noticed the order in the patient’s chart to clarify the fentaNYL x1 order to a patch and investigated. As it turns out, the fentaNYL 100 mcg/hour patch had been left on the opioid naïve patient post-procedure. Due to his quick initiative, Nelson not only prevented the major harm that would have impacted the patient, but also proceeded to educate the physician and nursing team as to when a fentanyl patch is appropriate for use to prevent future errors. Great catch, Nelson! 

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