Best practices: Controlled substance handling

Nurses Medications

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So I gave a controlled substance to my patient and then decided to straighten up the room before I left ... and promptly (absentmindedly) put the remainder of the ampule in the sharps container without having had another nurse waste it first.

So my options, as I saw them, were either to ask another nurse to "waste" with me ("How much do you trust me?" :sarcastic:), which I don't think is ethical since they didn't actually see me discard the remainder, or to admit to my error. So now I'm waiting for my pee test to come back, missing scheduled shifts since missing drug is a diversion investigation, and hoping that a big organization with rigid policies has room to accommodate honesty about a mistake.

Even though I know the pee test will be negative, I'm becoming paranoid :-). I've been a nurse for 7 years. I have a good reputation with my coworkers and I always try to play an honest game. But I've been thinking about all the things we do, every day, that could look suspicious even when they weren't intended that way.

Example: You pull a narc, get to the patient's room and they no longer want it, and you go from there to a bed alarm and an exploded ostomy and an "oh, whoops, your admit you didn't know you were getting from the ER just arrived" and it takes you 2 hours to get back to the med cabinet to return it. Or you have somebody watch you waste the remainder of a vial with you immediately, before you give the dose, but you forget to go to the computer and waste it with them there.

I would be interested in knowing (from people who are actually working on the floor and know how crazy it can be) what foolproof routines you have developed to keep yourselves absolutely above suspicion when it comes to the daily handling and wasting of controlled substances on the job.

Boomer MS, RN

511 Posts

Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.

I have done some floor nursing during my career. What I would do and did was to say, "I have a narc I need to have witnessed to waste. Can you come with me to do that now?" I did ED for 10 years and was able to make a narcotic waste a priority, especially since it was so common. For me it was a matter of priorities. If someone is in danger, that's a priority. If there is a code I needed to be with, I would put the waste in my pocket (I know, a no-no but really...what else to do?) and do what is more important at that time. I keep saying it is commonsense. Sometimes the appearance of evil is as bad as evil, so cover yourself. In nursing, however, there are times when things go wrong when all involved have done nothing wrong. Floor nursing is a very difficult environment in which to work.

Jump through the hoops and keep your head held high.

nutella, MSN, RN

1 Article; 1,509 Posts

Waste whenever you can right in the med room - that way you are not tossing it out by accident or forget about it...

I would have just asked another nurse to waste with me. In fact, I frequently do under those circumstances. Unless both nurses are there when the vial is opened, and the waste is discarded and witnessed right away, the wasting process is meaningless. When a nurse shows me 0.5mls of something that's been opened, I have no idea what it actually is.

Specializes in Reproductive & Public Health.

I always try to waste while I'm drawing up in the med room, but on a busy shift in L&D sometimes that is NOT an option, no way no how. In those situations I have taped the vial to the inside of my scrub pocket (with a lot of tape so it feels annoying), so it won't accidentally fall out and so I won't toss it in the linens when I change at the end of the shift, if I forget about it in all the chaos.

One time I went home with a half full vial of dilaudid in my pocket, and it scared the dickens out of me! I had visions of the DEA waiting for me when I came back in the morning lol. I was vigilant before that, now I am hypervigilant. Waste when you draw whenever possible, even if you think you might end up giving the rest of the vial 5 minutes later.

Hopefully your employer won't be punitive about an honest mistake that you were forthright about. Nurses divert by fudging their wastes and withholding from patients- not by pretending to throw away a dose and then self reporting the mistake!

Boomer MS, RN

511 Posts

Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.
Waste whenever you can right in the med room - that way you are not tossing it out by accident or forget about it...

Yes, best and ideal practice, but you still have to find another RN to come to the med room to be a witness.

dudette10, MSN, RN

3,530 Posts

Specializes in Med/Surg, Academics.

Here's what would be required to follow every step by the book in order to truly prevent diversion. Ready?

Open the MAR of the pt you are pulling for.

Pull the med from the Pyxis.

Have a witness stand there while you draw up the required amount matched to the MAR.

Label the new syringe that you've just pulled up the med in for pt safety.

Draw up the waste amount and put it in the sink.

Have your witness follow you to the room to administer the med.

Having someone follow you to admin the med you just drew up is the only way to prevent diversion completely.

See how ridiculous this is? No one does all those steps. Not even those facilities that are hard-nosed on procedure. Most wasting procedures have a loophole in them somewhere that those hellbent on diversion can leverage.

What happens where I work: Pull the med. If someone is there, waste in the Pyxis, and you are done with the "paperwork." If no one is there, go to the room, give the med, pocket the rest until two of you are in the med room at the same time.

One day, I had 9 tubes of meds in my back pocket to waste at the end of my shift. I had one patient getting q2 and one patient getting q3. Worst practice imaginable when it comes to preventing diversion, but it did not affect patient safety or safe med administration. Thank goodness everyone trusts each other when it comes to that stuff!

Why the heck did you create all this drama for yourself? Do you think no one has ever dropped a narc on the floor? Do you think no one has ever absent-mindedly dropped the waste in the sharps container before it was properly wasted/documented in the Pyxis? For this one silly oversight, just grab someone you trust and have them waste with you!

nutella, MSN, RN

1 Article; 1,509 Posts

Yes, best and ideal practice, but you still have to find another RN to come to the med room to be a witness.

Sure but you also have to find another RN when you waste somewhere else...

Unless it is a code or other emergency it is best to waste right there even if it means you have to wait for some minutes.

qaz99

17 Posts

That's odd. In Aus, you *have* to have 2 nurses present the whole way through a controlled drug administration. From the med room where you get the drug out, you dispose the remainder there and 2 nurses sign for the disposal in the controlled drugs book, then you walk together to the bedside, check ID and both nurses must see the patient swallow the med/nurse administer it. Seems to work well.

Its not common for nurses to be pulled up for drug diversions here because the system works. If I were to administer a controlled drug without another nurse present, for example, then there wouldn't be a second signature in the book which would be an immediate red flag within minutes to whoever next signed in the book.

qaz99

17 Posts

Having someone follow you to admin the med you just drew up is the only way to prevent diversion completely.

See how ridiculous this is? No one does all those steps. Not even those facilities that are hard-nosed on procedure. Most wasting procedures have a loophole in them somewhere that those hellbent on diversion can leverage.

But this is exactly what happens in Australia. It's not hard to find a nurse to follow you for 10 seconds.

i can't fathom how you guys are allowed to pocket remainder of narcotics until whenever you feel like getting a witness. Its asking for trouble and accusations.

nynursey_

642 Posts

Specializes in Med/Surg/ICU/Stepdown.

Honestly, I would have simply asked another nurse whom I have a good rapport with to waste with me, and vow to never make the same mistake twice. Going through the nonsense of a suspected 'drug diversion' when you made a simple error seems excessive. We make mistakes. It happens.

To avoid it in the future, I always waste my narcotics AT the Pyxis prior to leaving the med room for the med pass. If I know it's a partial dose, then I grab another nurse on my way into the medication room, and waste right then and there. It's the easiest most fool proof way to avoid having to go back and remember to have the vial WITH the unused medication in hand in order to perform the waste. Furthermore, liquid narcotics (and pills) are disposed of in the sink, and it's easier to waste your partial dose in the med room prior to administration than to pull it out after administration and ensure it measures properly.

Here's hoping you make it back to work in a speedy fashion!

brownbook

3,413 Posts

This is one of the more stupid scenarios I have read. If I saw this on a TV drama I'd be rolling my eyes! There are many instances over the past 30 plus years of nursing where co-workers, myself included, have done similar things. We trust each other.

I have caught a nurse diverting, I am not naive about diversion. I still maintain this is ridiculous overkill!

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