I actually work inpatient psych and my count was off by one this am. We have a paper system which is horrible, all the lines...lol...Anyways, I have been there for about a month now, new grad since May and I have never had a problem with the Narcs until today. I worked 3rd shift, it was a quiet night and the only time I was even in the Narc drawer was to count at the start of my shift! Well, I PHYSICALLY put my hands on every-single med, inspected them for color and shape...while the off-going nurse called out her change of shift numbers...sounds good right?? Well, when we counted, the numbers matched flawlessly....Time to leave my shift the next morning, and the next to last Narc was off by one!! I was looking at the on-coming nurse who had just counted with me, her hands currenlty in my Narc drawer telling me one is missing (don't be judgemental!!)......SCARY.....I thought to myself....I haven't been in the drawer all night...it's impossbile....then we had to notify the Nursing Supervisor.....while waiting like a criminal waiting to be executed I frantically searched the old MAR's for the missing dose....5 minutes of agonizing fright and I found it.....the previous nurse had documented in two seperate places as our policy stipulates (thanks GOD!) that she gave the drug, she just did not document/subtract the dose from the Narc count. Who's to blame??? Both of us......I am just as guilty for only looking at the pills themselves and not observing the number that the off-going nurse is recording on the Narc sheet....LESSON LEARNED.....the scariest feeling in the world to have a missing Narc and a brand new license! BE CAREFUL.....I will in the future slow the turn-over process down a bit and ensure that what I physcially count, the number recorded on the Narc sheet and what the off-going nurse says all match...because once I accepted the keys it became my problem. I HOPE SOMEONE ELSE CAN LEARN FROM MY MISFORTUNE. I was lucky in the fact that the nursing supervisor was very supportive, they never accused me of being a Narc-Thief......but it felt like the whole world was pointing the finger at me......horrible feeling....don't let it happen to you! Because I did not observe the written number, I could have jeopordized my career. If I would have looked at the number with the off-going nurse I could have caught the error and saved myself a lot of problems. By the way the off-going nurse is a Great Nurse, she's just happens to be human like the rest of us! Once the person you counted with is gone...it's truely up to you to defend your license!!!!
On the way home I was thinking to myself....what if I could not have found where the med was dispensed....I would have provided a urine sample which would clearly exonerate me right?? Well, of couse my UDS would be clean...I don't even take any prescription drugs, barely Tylenol...I should be good right? Not exactly, if they could not have found the drug...just because I my UDS would have been clean would only have proven that I did not ingest the Narc....that still would not without a shadow of a doubt prove that I did not remove the Narc with intent to commit a crime!!!
PEACE, BE CAREFUL OUT THERE AND MAY GOD BLESS!