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Our hospital pharmacy has a white board for updates and statistics tracking that has a section called "Good Catch." Let me tell you, some of the things I've seen on that board...THANK YOU for sparing us. (KCl labeled as asa? As a critical cardiac care nurse, I am duly horrified.)
Trust me, so are we. Typically, the reason for the mislabel is due to the machine that is used for pre-packing from stock bottles. For the most case, standard meds are given their own containers for the machine, but when there was a KCL shortage going around something happened where a standard container was used for a non-standard medication and they didn't make sure the old container was cleared before adding the new medication.
That being said the pyxis pharmacist checking, should have looked at EVERY pre-packed med (100 per batch typically) and see that they all looked correct (eg: no doubles, empties), and would've seen the size mismatch between the 2 meds lol. We have some great techs though and one of them caught it as they were doing their pyxis load.
Love my crit care nurses though! We have 5 ICUs (+ ER/Trauma) and most all those nurses typically have their stuff together, which makes my job much easier, when I gotta call with questions! So, thank you for being on the ball!
I mean my second thought after sheer horror was that I'd definitely notice this baby aspirin is uhhh...a giant horsepill? That would seem very odd. But like on my end what am I supposed to do to verify, lick it? 😂
And we appreciate the shit out of you right back. The number of times we've had something going down and called pharmacy: "Hey I have a stat order for..." to be interrupted with: "It's already verified."
Seriously, thanks for everything you do for us.