I work in a fairly small state operated facility. We are going through some tough times right now with talk of being closed down. We just had 2 LPN's quit this week, one had been there for about 6 months and one for over 2 years. One is on sick leave so that leaves me as the only LPN in our building (I said it was a small facility). Anyway, yesterday there were two CMT's passing the meds during the day and two RN's were in the building. I came in and went through my usual routine, setting up the cart, counting narcs etc. Nothing seemed out of the ordinary. We rotate the two carts we have so that no one gets borded or fed up with one, ususaly every week. This was my first day back on this cart having not been on it for a week. When I was doing my 8pm med pass I came to an individual who takes Valium 2mg and when I was ready to pop the pill from the bubble pack, I noticed it was taped back in. This is somewhat unusual, but not totally unheard of since our carts are too small for the meds that we need and somtimes the bubble card behind will punch through the foil; but I noticed it. It wasn't a Valium! I wasn't sure what the pill was but it was obvious that it wasn't what it was supposed to be. I immediatly called my RN and explained the situation to him and followed his direction of what to do next. (Give the next pill, which was also taped but was a Valium and save the other pill for him to look at and see if we could determine what it was.) Well, this really bothered me and I began looking through the narc drawer to see if it was another narc that had fallen out of it's card and couldn't find it but then noticed another pill taped back in a card that didn't match the rest! Long story short(er), the pill in the Valium card was a 50mg Atarax and the other one was an 81 mg ASA in a Tranxene 7.5 card! I have no idea what to do, I mean it is out of my hands for now, I told my RN of the situations and told him what I had found and he immediatly called the "med room supervisor" also an RN and told her of it. He basically told me to watch really closely when I was counting and check every card for tape etc, but not to say anything because if it happens agian then we will know it was intentional. Neither of the people who's narcs were tampered take the medication that was in their card, and as far as we know neither of them are allergic to what was in them either. At the rate the facility is going, I wonder if it was someone trying to set us up, an innocent mistake, or someone taking the drugs. As I said, I was not on that cart for a week, so I have no way of knowing how long the tape has even been on those cards! Any input on this situation would be helpful!
Apr 13, '05
You did the right thing by reporting it. I probly would have written an incident report also though, just so it was on the record that you found it and didnt DO it and WHO you reported it to.
We have instances when a patient has refused a prn and occasionally we will tape it back into the package and put it in a cup and leave it in the cassette for that patient until the end of the shift. But it is eventually wasted at the end of the shift, not left in the supply. I dont know that someone is using the medication, that implies you dont trust your co-workers and if that is the case,, get out now.
I think someone screwed up and was afraid of having possibly "another" medication problem to answer for.
Last edit by meownsmile on Apr 13, '05