Narcotic Discrepancy!!

Nurses General Nursing

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Okay so I previously had an account on her but changed my email and cannot remember my login info. I am going to try to give as much info as I can to get an answer without too many details.

I work in a LTC facility. It was found during change of shift count with two RNs that a liquid narcotic in the med dispense was actually just an empty bottle. There are two bottles of same med kept in the same drawer. One was fine other was empty. Everyone that has been in med dispense for certain amount of time was called in for statement and interviews.

I was not in the drawer in question to pull the med. I did however help an RN restock a bottle about a week and a half ago. I confirmed there was one bottle in the drawer and we were adding one. I neglected to actually look at the liquid in the bottle. I know this was a mistake on my part but two nurses check it in from pharmacy and I trusted the RN that restocked it. (Won't ever make the mistake of not looking at contents again!). There is no way to tell if the bottle we put away or the bottle that was in the drawer was the empty one.

The med gets counted every change of shift so it has been counted at least 16 times since we put in drawer. I am now freaking out because I can't say for sure the liquid was in the bottle at the time we restocked and I'm afraid they will come back on me for not checking. I still fully trust the RN and know she did not tamper with the med.

I'm not looking for any legal advice but wondering if anyone's been in the situation or known anyone with a similar situation. I'm freaking out as I'm very pregnant and can't afford to lose my job! We've all offered to be drug tested but I know that can't account for people stealing for other reasons. I don't understand how someone could even take the liquid out as it takes two to open the drawer and anyone can enter the room at any time! Any feedback would be appreciated!!

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Specializes in ICU.

I would say that if there have been that many counts since you last had any access or anything to do with that med then you should be fine.

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I would say that if there have been that many counts since you last had any access or anything to do with that med then you should be fine.

Thanks for replying! I am hoping this is the case and intend on fighting if I am fired since so many hands have been in the drawer since but I can't help but worry! I've seen them make an example of people and good nurses lose their job. I will definitely be refining my practice and taking responsibility in my part of the issue.

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The med gets counted every change of shift so it has been counted at least 16 times since we put in drawer. I am now freaking out because I can't say for sure the liquid was in the bottle at the time we restocked and I'm afraid they will come back on me for not checking. I still fully trust the RN and know she did not tamper with the med.

You actually don't "know" that. Sometimes the person who diverts turns out to be the last one you'd ever expect. I'm not saying she did it, just that you really only "know" what YOU'VE done.

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How much SHOULD have been in the bottle? was there any evidence of spillage? Was the bottle accessed on a regular basis?, if so were the doses accurately subtracted?

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How much SHOULD have been in the bottle? was there any evidence of spillage? Was the bottle accessed on a regular basis?, if so were the doses accurately subtracted?

15mL should have been in the bottle. They come half full from pharmacy for the med dispense. They take a full bottle and split it into two. No sign of spillage according to the higher ups. We do not give from the bottles in the med dispense. If we need to pull a bottle we get an auth code from pharmacy then pull and use the bottle for that resident only. They come with the red tamper wrapped around the lid and bottle. The higher ups showed us the bottle and the sticker was completely removed but the RNs that counted said the tamper sticker had only been "pushed down" so not sure about that detail.

The bottle was not stained at all and usually they are very stained from laying in the drawer. When I mentioned that to them they opened the bottle and showed me that there was a red film caked at the bottom of the bottle so there had obviously been med in there. One nurse is convinced it evaporated but I don't know how 15mL could have.

The odd thing is the night that we restocked the morphine, we had called pharmacy because dayshift had pulled a bottle and it was so stained it was impossible to count. We had asked if we should waste and pull the other bottle or if they could send an empty one. They told us to hold the med until morning and they would send a new bottle specifically for the resident and then we could waste the stained one. The resident ended up passing away that evening so no new bottle was needed.

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Specializes in Psych ICU, addictions.
You actually don't "know" that. Sometimes the person who diverts turns out to be the last one you'd ever expect. I'm not saying she did it, just that you really only "know" what YOU'VE done.

Anyone is capable of diversion. It doesn't have to be the nurse that looks strung out and is giving off all the signs of possible substance abuse, or the nurse who everyone knows has the criminal record or the past history of drug use. It could be little Ms/Mr Perfect Nurse. It could be New Grad Nurse or Crusty Old Bat Nurse. And given the rate of substance abuse problems developing among healthcare professionals, it could one day even be You (any of you).

Do not fall into the trap of blindly trusting anyone. If you are there to witness, insist on verifying the contents and amounts yourself. If the other nurse is truly innocent, they won't be offended.

And if failing to properly verify for yourself comes back to haunt you, don't rely on a negative drug test to automatically save your hide, i.e., "the drug test will set me free!" Employers know that not everyone who diverts immediately runs into the bathroom to guzzle it down or shoot it up. They may use it later, or they may never use a drop but sell/give it to someone else. So CYA with properly verifying.

Now that I've scared you witless, going back to the problem at hand...

As it's been quite some time since you last witnessed it and the discrepancy being noticed, I agree with the PP--you're probably fine. A lot has gone on since then and more keeps going on as time progresses--it would make it more difficult to fully pin it on any one person. Who's to say that there weren't other restockings and verifications that you weren't involved in? I think you're OK

That being said, if they pursue the matter further, consider seeking legal counsel, especially if you are innocent.

And from here on out, don't be lackadaisical with narcotic counts and verifications again. As you said yourself, you knew it was a mistake on your part.

Best of luck.

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Specializes in LTC and Pediatrics.

I don't know if you do this, but if yo don't you may want to start. Is the bottle looked at at every narcotic count? If that is done, you would notice the discrepancy sooner. When we do count, we pull the bottles out and look at how much is in it. Even those which have not been opened.

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Specializes in retired LTC.

How much would a usual dose to be given be used from that bottle? That is, how much do you pour off in one administration?

Is one dose equal to 15cc? Maybe somebody didn't just sign for the last dose?

I'm sure you've tried comparing all the doses given on the MAR to match the narc record.

I HATED NARC LIQUIDS. Somebody always would be overly sloppy and small volumes would be 'lost' benignly. But all those little volumes do add up.

And I find it very hard to believe that 15cc could 'evaporate'. That's like a tbsp! It would take forever for that volume to evaporate in a closed capped bottle!

COBs will remember the old multi-dose Demerol that used to always come up short because some nurse would 'shoot off' into air from an overfilled syringe. Remember that?!?! Cringe! Cringe!

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I don't know if you do this, but if yo don't you may want to start. Is the bottle looked at at every narcotic count? If that is done, you would notice the discrepancy sooner. When we do count, we pull the bottles out and look at how much is in it. Even those which have not been opened.

I actually don't do the shift to shift count as I work as a floor nurse and not the supervisor. Apparently the supervisors have not been looking at the liquid in the bottles and only that there are bottles of the right count in there. This is obviously going to change now! This is why they are having such a hard time pinning down what happened!

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Anyone is capable of diversion. It doesn't have to be the nurse that looks strung out and is giving off all the signs of possible substance abuse, or the nurse who everyone knows has the criminal record or the past history of drug use. It could be little Ms/Mr Perfect Nurse. It could be New Grad Nurse or Crusty Old Bat Nurse. And given the rate of substance abuse problems developing among healthcare professionals, it could one day even be You (generic).

Do not fall into the trap of blindly trusting anyone. If you are there to witness, insist on verifying the contents and amounts yourself. If the other nurse is truly innocent, they won't be offended.

And if failing to properly verify for yourself comes back to haunt you, don't rely on a negative drug test to automatically save your hide, i.e., "the drug test will set me free!" Employers know that not everyone who diverts immediately runs into the bathroom to guzzle it down or shoot it up. They may use it later, or they may never use a drop but sell/give it to someone else. So CYA with properly verifying.

Now that I've scared you witless, going back to the problem at hand...

As it's been quite some time since you last witnessed it and the discrepancy being noticed, I agree with the PP--you're probably fine. A lot has gone on since then and more keeps going on as time progresses--it would make it more difficult to fully pin it on any one person. Who's to say that there weren't other restockings and verifications that you weren't involved in? I think you're OK

That being said, if they pursue the matter further, consider seeking legal counsel, especially if you are innocent.

And from here on out, don't be lackadaisical with narcotic counts and verifications again. As you said yourself, you knew it was a mistake on your part.

Best of luck.

Thank you for your reply! I will definitely always be checking the actual liquid in the bottle no matter who the other nurse is! I have learned my lesson and it was my lesson to learn because it's just good practice. I will be obtaining legal counsel if it gets to that point. There were at least 16 counts (we work 12 hour shifts but sometimes the supervisors split shifts so there could have been more) in between when I consigned the restock and when they found the empty bottle. That was the only time I was in that drawer but they are waiting for the full report from pharmacy to see who all the change of shift counters were.

I was honest in my statement and told them that I did consign to restock a bottle on the date I worked and that I failed to observe the actual liquid in the bottle we were adding and the bottle that was already in the drawer. I saw a bottle in the drawer and saw the nurse add 1. May not have been the smartest thing but I couldn't in good conscience say I saw the liquid when it may have been empty at that time. :/ I know many of the supervisors including the acting DON (is actual ADON) also stated that when doing counts they count bottles and fail to look at the liquid. This practice will obviously be changing!

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How much would a usual dose to be given be used from that bottle? That is, how much do you pour off in one administration?

Is one dose equal to 15cc? Maybe somebody didn't just sign for the last dose?

I'm sure you've tried comparing all the doses given on the MAR to match the narc record.

I HATED NARC LIQUIDS. Somebody always would be overly sloppy and small volumes would be 'lost' benignly. But all those little volumes do add up.

And I find it very hard to believe that 15cc could 'evaporate'. That's like a tbsp! It would take forever for that volume to evaporate in a closed capped bottle!

COBs will remember the old multi-dose Demerol that used to always come up short because some nurse would 'shoot off' into air from an overfilled syringe. Remember that?!?! Cringe! Cringe!

These are bottles we pull and use only for one resident so none of the med should be used while in the med dispense. It is a strong narcotic and the largest dose which would be very large would be 1mL at a time. Usually we give 0.25-0.5mL of the med but again we only do that after we pull the bottle under the resident's name. Then it goes into our locked narc box on the med cart. I also don't buy that the med could have just evaporated as it is a very large amount of liquid and I don't believe either bottle had been in there for a long period of time.

Normally I wouldn't even be so worried since there were so many counts between me restocking with the nurse and them finding the issue but when a narc comes in from pharmacy we take two signers to verify. The sheet they pulled from that night only shows the nurse I restocked with as a signer so no backup that the bottle had anything in at that time. So either someone forgot to sign the paper when they checked in meds with her or she failed to get a second person to check. In which case she is really in the hot seat as she has also participated in a lot of shift to shift counts as well.

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