I Lost a Medication: Controlled Substance

[GreenApplesauce]

Hey Guy,

I am a med-surg nurse for the past 4-5months. Things are great as far as I know, until today....I lost a dose of Ativan.

I had a pt that was to get a scheduled dose of Librium. I pulled Ativan because she was having some anxiety. Upon administering the med, it had instructions to space out the Librium and Ativan by two hours. So I held the Ativan and gave the Librium.

I kept it in my pocket, by the time I went back to the Pyxsis to return the med with a witness, I could not find it. I emptied out my pockets, checks all the rooms I went into, even the bathroom. Nowhere to be found. I informed the charge nurse and she called the pharmacy.

I filled out some documentation stating what happened then I went home after my shift.

This a a huge bummer. I have never had this happen before.

Who knows where the med went. Whether someone found it and kept it for themselves or it is somewhere in the piles of garbage. I even checked the garbage, could not find it.

I am really worried. Could I get fired for this? How serious of an offense is this?

I am bummed. I just started to get used to working in the hospital. I feel like whenever I feel like I am catching up, a wrench gets thrown in the mix.

Does this happen? What should I prepare myself for in terms of disciplinary action?

Thanks so much for the advice.

[cienurse]

Ah.... I am just a nursing student and have not yet started clinicals, but I am SO absentminded and have a tendency to lose things. Any tips for avoiding something like this happening?

Yes, NEVER put meds in your pocket!! It's not a good habit to get into. If your facility doesn't have a policy for how to transport controlled substances from one floor to another without having to pocket the meds, ask for one. No nurse should ever be put into a position of having to carry meds around in his/her pocket, especially controlled substances.

[HappyWife77, BSN, RN]

I'd like to offer a tip if I may. I keep separate pockets for different things. For instance, my right-hand shirt pocket is for "clean" or important stuff I keep, such as my cheat sheet, meds, whatever. My left-hand shirt pocket is for "dirty" stuff, such as wrappers and other stuff that I don't keep. My right-hand pants pocket is for my Kleenex...etc. If you do that, you'll not risk again pulling out and dropping by accident something you want to keep. I know a nurse who actually keeps a little coin purse in her pocket to keep meds in because she has to go off-unit to get them.[/quote']

Great Tips!

[StNeotser, ASN, RN]

Oh I lost an 0.5mg Ativan once too because a patient refused it. Years ago. Of course I wasn't going out of the room with my hands empty, I had the souffle cup with the Ativan in it and a bag of trash. When I returned to the nursing station after dumping the trash I had the cup but no Ativan. We looked for a while, couldn't find it on the floor or anywhere. The unit manager at the time just had me sign the form. I was so worried and she said "This happens. If it's a frequent occurrence THEN we get suspicious"

I don't want to dare say I've never lost a med since in case I jinx myself but you'll find yourself being very careful in future.

[RN2B123]

We don't have a Pyxis on my unit (I work in Psych) and we still do the old school med in a bottle like you'd keep at home in your cupboards. Can you believe that we don't even '' count'' Ativan or keep track of how many pills we have etc it's just if you need one take it out of the bottle that's in a cupboard. I was surprised by this when I started my job - I just assumed meds like this would be counted and tracked... Guess not!

If we get morphine or painkillers up we have to do narc counts but for stuff like ativan or other benzos/sedatives and similar stuff we don't at all

[GreenApplesauce]

Thanks for the responses.

Lesson learned. Sometimes I feel on my floor we are set up to fail. That day, I had 3 patients to start, an out patient antibiotic transfusion, a discharge, picked up someone else's patient in the middle of my shift and took a direct admit.

When I originally wanted to return the med, there were no nurses in sight or the charge nurse, to be a witness so I could return it to the pyxis. I could not just stand there waiting for someone to show up so I could return the med, so I kept it in my pocket, while I completed other tasks.

I give 150% when I am on the floor, I am lucky if I get two breaks during my 12hours shifts. I try to get at least 1 break. That is a blessing.

This is the hardest job I have EVER had in my life. I feel, even when I give my all, there is still room for something to go completely wrong. I guess with time things will get better and I will be more in sync. This is just another issue I will have to deal with.

I will definitely not let this happen again and I will track down someone immediately to return the medication to the pyxis and never keep meds in my pocket.

[dishes, BSN, RN]

We don't have a Pyxis on my unit (I work in Psych) and we still do the old school med in a bottle like you'd keep at home in your cupboards. Can you believe that we don't even '' count'' Ativan or keep track of how many pills we have etc it's just if you need one take it out of the bottle that's in a cupboard. I was surprised by this when I started my job - I just assumed meds like this would be counted and tracked... Guess not!

If we get morphine or painkillers up we have to do narc counts but for stuff like ativan or other benzos/sedatives and similar stuff we don't at all

In this type of situation pharmacy is tracking the count.

[RN2B123]

I don't think pharm tracks the count in our situation I'd be really surprised if they are. I see them come up and they never take a look

[BSNbeauty, BSN, RN]

Calm down, OP. If you find it at home then you should take it . No, I'm just kidding. I would just notify the manager. Better to be upfront and honest about it.

[TerpGal02, ASN]

We don't have a Pyxis on my unit (I work in Psych) and we still do the old school med in a bottle like you'd keep at home in your cupboards. Can you believe that we don't even '' count'' Ativan or keep track of how many pills we have etc it's just if you need one take it out of the bottle that's in a cupboard. I was surprised by this when I started my job - I just assumed meds like this would be counted and tracked... Guess not!

If we get morphine or painkillers up we have to do narc counts but for stuff like ativan or other benzos/sedatives and similar stuff we don't at all

Same thing here. We DO have a pyxis though. You pull out an Ativan the same way you'd pull a Zoloft or Atarax. Pyxis asked you to verify the count, but it gives you the count (like count is 10 is this correct?). I do know pharmacy keeps track of it but you don't have to follow the stricter procedures with benzos like we do with stims or opiates. In fact if someone's on a PRN benzo, pharmacy just sticks it in the patients med drawer on the cart.

[dishes, BSN, RN]

I don't think pharm tracks the count in our situation I'd be really surprised if they are. I see them come up and they never take a look

Ask your pharmacist how the ativan, benzos and sedatives are tracked.

Why would you be surprised that they would audit for diversion?

[Sugarcoma, RN]

Yes this happens. More often than you would believe. Worst case scenario is that you will be drug tested. They may monitor your pyxis pulls a little more closely. You may have to meet with the educator to review medication administration. Just be aware that since pharmacy is involved, even if your manager wanted to give you a pass, he/she may no longer have the option to do so. I am sure there is some type of protocol in place for situations like this. If I were your manager I would certainly take into consideration the fact that you are very new to the specialty and that you alerted the charge nurse as soon as you realized what had happened.

Many nurses have med administration issues. I know that I have turned patients and discovered pills, even full IV piggyback bags underneath them. I know many nurses who forget to waste or forget to chart prns etc. It is so common that I never bother to check the mar to see if a patient is due for a pain med, I check the pyxis for the last dose pulled.

I lost two percocets once. Had just pulled them for my patient when another patient on the unit pulled out his chest tube. His nurse was 1 week off of orientation and did not know what to do, so I ran in to help and set the cup of meds on the patient's IV pump. In the commotion of inserting a new chest tube and bringing in all the equipment to do so, the iv pump got flung across the room. I found the cup overturned in the corner of the room. Never did find the pills. I was mortified. I had been a nurse for about 6 months. I was certain I would be labeled a diverter. I called my manager at home and she was beyond supportive. She had me waste the meds with another nurse in the pyxis and told me if questioned to simply tell the truth, the meds fell on the floor so I had to pull new ones.

Nursing is multi-tasking on steroids. Things change so quickly and there are so many demands on our time. How many times have you been in the middle of a med pass to have a patient need you or a family member interrupt you, or a doctor call, etc. We are only human and every single one of us makes an error. Considering what we do every day there are far worse mistakes that could be made then losing a pill.

[RN2B123]

Ask your pharmacist how the ativan, benzos and sedatives are tracked.

Why would you be surprised that they would audit for diversion?

No I've even asked my nurse manager that shouldn't we be keeping track of them and our manager was like no we don't count meds like Ativan. For example if we drop a pill nurses just discard the pill (people were just tossing them in the sharps bin until someone left a note saying not to do this) or just toss it out... From my knowledge I'd be shocked if pharm actually tracks it just bc i know everyone on my unit just tosses expired or dropped meds away. That was my main concern when I started I was saying how easy it would be for someone to just divert or steal meds cause they don't seem to keep track at all... Maybe they do and I just don't know but with what I've seen on my unit I'd be surprised that's all. I wish we were more strict. I guess I could always ask pharmacy what they do on their end... Just curious I guess bc other hospitals I've been at during school before I started working all had Pyxis and they just seemed alot more on the ball and strict w everything

I also live in Canada - where I have never heard of drug testing in hospitals or even for nursing school - its just not done here for some of reason. I agree with it and I know the USA for the most part drug tests nursing students and even random drug tests for staff in hospitals - I was surprised that they don't here bc it does make alot of sense to me. I wonder why there's such a difference between CDN and USA hospitals in that regard. I know if they suspect diversion then I'm sure they would drug test but for just random tests and testing for entrance into NS... Forget it. I've read on Allnurses too before the same thing... Other CDN nurses have said the exact same thing as me