What do you do when the narcotic count is off?

[flashpoint]

Last night I went into work and things were going pretty well until we did the narcotic count. According to the narcotic book, one of our residents was supposed to have 28 dilaudid...there were only 26. The pharmacy had just delivered the dilaudid about an hour before shift change...the day shift nurse said that she was too busy to count with the pharmacist, so she just signed the book along with him. She crossed through the 28 that the pharmacist had written and wrote, "Count correction - pharmacist delivered 26 dilaudid, not 28." She then sighed her name and told me I needed to sign after her to resolve the discrepancy. I told her that I would be happy to sign that there were only 26 tablets, but that I had no idea where the two missing tablets were, so I was not going to sign her correction. She then informed me that she is and RN and that I have no choice but to do what she says. I explained that I honestly had no doubt that the pharmacist only delivered 26 tablets (it is a mistake he has been know to make), but since she had signed off that he delivered 28 and since I had no idea where the missing pills were, I was not going to sign. She was obviously angry...her tone seemed threatening. She told me that she was going to call the DON if I did not sign...I told her to go ahead and call because I was not backing down. I tried to call the pharmacist three times and got no answer at the pharmacy, his home, or his cell phone. I also tried calling my DON to see what she wanted us to do, but she didn't answer. I was very comfortable signing that there were only 26 tablets, but I was not comfortable with her explanation. So...she documented in the narcotic book, "Cotjockey refused to sign this count correction, despite direction from RN." The pharmacist did call this morning to say that he found two dilaudid just sitting on his counter...that is where the missing pills were.

Was I wrong not to sign? I really don't want to get in trouble with my DON, but I really, really don't want to get in trouble with the state board...also if there is disciplinary action against one license (LPN), they usually bring equal action against another (paramedic). I worked too hard for both to lose either one or be on probation or anything else. Also, the EMS board is really strict...you can usually get a nursing license back...the EMS board is not so forgiving.

[babynurselsa, RN]

Maybe so Tazzi, but that was still her boo-boo. She knew better.

But on the dark side, what if this person had diverted, and then bullied someone into signing off missing dilaudid...?

[flashpoint]

I was about 99% sure that the pharmacist had messed up...he gets sloppy and does things like that. This nurse is his biggest critic though, so I can't believe she just glanced at the cassette and signed the form. I do feel sort of bad for her though...the pharmacist shows up right in the middle of supper every day and the supper med pass is pretty big. I also know for a fact that this nurse is pretty sensitive to medications...I've taken care of her a couple times when she has been in the hospital, so can't imagine that she would be diverting.

Narcotic counts is one thing that I am very by-the-book about. Very early in my career, I counted narcotics with an agency nurse. While we were counting, I noticed that an entire package of Valium (I know, not a narcotic, but we counted it) was missing. I didn't speak up though because the Valium had been D/Cd, there was no sheet on it, and the pharmacist had been in that day to destroy meds, so I just assumed it had been pulled and destroyed. Nope...it wasn't on the destruction log and the narcotic sheet from the book was nowhere to be found. Now if we having something missing, I check the dectruction log before I'll sign off...it drives people crazy sometimes, but oh, well.

Thanks for the words of wisdom. I was pretty sure I was right, but it's always nice to have a second opioion or two.

[banditrn]

As an RN in LTC, I consider the LPN's on equal footing with me. We all do the very same job. Where did this gal consider herself the boss?

At the hospital, if the count was off it was taken very seriously - but they seem to be very lax about it in the LTC where I work now.

Recently, there was a shortage two nites in a row, so I called the DON to report it and ask what the procedure was - well, I got told not to make such a 'big deal' out of it and in the future to just leave her a note.:uhoh21:

[PANurseRN1]

Panic!

Just kidding. This is rarely an issue since we use AccuDose.

[onlyanrn]

I diasgree with most of what has been said. Whatever happened to teamwork and supporting one another? I, for one would have had no problem signing the corrected count. Do you really think someone would lie about a mere to pills? Nurses need to stick together if we expect to remain a profession. Accept her ansewrs and show her that you respect her by giuving her the trust she deserves. TYou ended up being wrong and she right, didn't you?

[catlady, BSN, RN]

I diasgree with most of what has been said. Whatever happened to teamwork and supporting one another? I, for one would have had no problem signing the corrected count. Do you really think someone would lie about a mere to pills? Nurses need to stick together if we expect to remain a profession. Accept her ansewrs and show her that you respect her by giuving her the trust she deserves. TYou ended up being wrong and she right, didn't you?

Obviously you're never worked with someone who diverted meds. I hope you never do. Then you wouldn't say what you just said.

Yes, I really do think someone would lie about a mere two pills. This has nothing to do with teamwork; it has everything to do with integrity, keeping your license, and staying out of jail.

[nursesarah]

two pills might not seem like a lot. but two pills here, two pills there, and it all adds up. nurses need to remain professional if we expect to remain a profession. this means respecting the checks and balances in place that are meant to protect our licenses.

[babynurselsa, RN]

Only an rn, I see that you are new and the only posts I have seen of the 8 you have made have been argumentative. YOur response to the above posts are actually a deviation from the standars of care and illegal.

THe above mentioned secision has NOTHING to do with teamwork. I lie for no one. If I did not see it and document that I did that IS a lie. Get caught and kiss your license goodbye.

[jetscreamer101]

You were right in refusing to sign for the discrepancy. And I would sign the correct count, just not the discrepancy. I've learned to always count. I've come across scheduled meds that were obviously not given (same count from previous shift and should have had one that shift), missing doses(3 duragesics gone,no-one knows where to and for 3 days no-one had actually counted the narcs-just assumed the last nurse did and the count would be ok), diversion (asked patient why they were using so much vicodin lately only to be told "all I've been taking is tylenol"), wrong doses given(5cc of roxanol gone when the dose is 5 mg or .25cc). So now, I always count.

[Antikigirl, ASN, RN]

You didn't do anything wrong at all!!!! Good for you to stick to your guns! NO way would I have signed that at all! If something had gone wrong...you would look as guilty as the others if you had signed! No thanks!

What you did, calling the pharm and DON was exactly what you should have done...actually the other nurse should have done! If I see a probelm with narcs...I call my charge nurse right away and get it all witnessed and documented right then and there! Like someone said...short of a code, I will stop and get that handled right away or put into the hands of my superior to handle/investigate.

What you did was right! And I think that other RN should be repremended for a potential 'cover up' or documentation fraud! (she can't have you document something you didn't see or do! That is fraud if you had signed for both of you!).

[babiesX2]

Cotjockey, you absolutely did the right thing by not signing.

[TazziRN, RN]

Onlyanrn, you would be a diverter's dream person to work with.