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.

[dishes, BSN, RN]

I live in Canada too and am familiar with the style of medication administration you are talking about. Staff have complacent attititudes until the day a collegue is caught diverting, then they realize the controlled drugs are being audited, as it is the pharmacist's manual audit that led to the discovery and proof of the diversion. I would ask the pharmacist about what is best practice for wasting controlled drugs.

[HeyHeyitsMaay]

I did the exact same thing also! I lost an Ativan..it was so tiny and I even tore the trash on my med cart apart looking for it. Depending on the facility you should be o.k. I would offer to take a drug test and let it be a lesson that makes you implement steps in your med pass procedure that prevent it from ever happening again.

[DisneyNurseGal, BSN, RN]

As a student, I watched a nurse accidentally put an unused (full) of Valium in the sharps container. She had the used syringe in her hand and just got them mixed up. Not sure what the ramification are, but just take it as a learning experience.

[amoLucia]

Meds should never, ever be put in your pocket. Think of it as a lesson learned.

Don't put syringes, used or clean, into pockets either. Accident waiting to happen!

[Jory, MSN, APRN, CNM]

We had our narcotics books go missing in the Radiology dept at my hospital once. We were all drug tested and a new book started with fresh counts. The drugs are kept in lock boxes in each procedure room there and counted at the beginning and end of the day. With the count boom missing, any number of mess could have been taken. The cabinet had fentanyl, versed, morphine, and valium.

You did the right thing reporting it. I would expect for you to be counseled and possibly drug tested but wouldn't expect you to lose your job. That is a possibility but typically employers understand we're human and these things can happen.

Other than a drug test, nothing should happen...not even a write up. I am very careful that the pockets that I wear to work are NEVER from an angle...they are always open to straight in.

Things happen..what they shouldn't do, is happen all the time.

You'll be ok...don't sweat this.

[TiffyRN, BSN, PhD]

Back when I worked in the adult world, I would pull the med from the pyxis, put it in a med cup, take it to the room. If the patient refused or for whatever reason, the pill didn't get given, I would tape the pill (generally in the package) to the back of my ID badge, over the part that scanned me out. That way, it I forget to return the med, I would have a sudden reminder when I was unable to badge out at the end of my shift.

Very early in my career, I nearly took home a vial of diazepam from several that had been in my pocket for a terminal patient in status epilepticus that we dosed very frequently. That was in the days when we only counted Schedule IIs and IIIs, so diazepam and other benzos were not tracked closely, I'm not even sure we recorded waste for those (ok, so it was over 20 years ago). We still had respect for benzos and would have been in trouble for taking any home so I guess that experience helped me come up with a way to keep better track of my scheduled meds.

[Munch]

Back when I worked at Sloan-kettering(oncology hospital) we obviously delt with A LOT of Narcs and Benzos. Pretty much 98% of the patients were on some controlled substance or another. I once lost a syringe of demerol. I was at my patients bedside hanging compazine, hung an antibiotic, drew up and administered ativan and just as I drew up the demerol the patient's roommate had went into anaphylactic shock from one of the many antibiotics being given. So I had to stop right then and there, call the code, help with the the code...etc. When the chaos was over the syringe with the Demerol in it was gone from my pocket! I think we are seeing a common denominator here...don't put meds in pockets! I told my supervisor who totally understood as she has been there for some of the chaos. She just had me write a statement and nothing materialized from the incident...I didn't even have to take a drug test.

[Cobweb]

So...several people have said not to put meds in your pocket, but they haven't said what to do with them (except if they need to be put back--I think taping them on your badge is a good way not to forget about one pill, but it obviously won't work in many situations). If you don't put meds in your pocket, what do you do with them? For instance, in the situation mentioned above, where a patient is going into anaphylactic shock, there are lots of people in the room, plus another patient. You can't leave it on the table, you can't hand it to somebody else, and you probably aren't going to work one-handed until the crisis is over.

[jamd11]

It's never even crossed my mind to put pre packs in my pockets. I'm quite sure its not best practice. I've worked with pyxis, pharmacy made blister packs and straight from the bottle. When working with pyxis I would take the client's drawer with the mar and pull all meds. I'd take them back to my med cart and perform my pass. The go in the med cup/ syringe right away and straight to the room. If someone comes up to me I tell them in the middle of meds, I'll find you in 5 mins. If its an emergency its an emergency and I do my best. If a client refused a controlled substance I would discard is asap or it would be locked back in the med cart until I could discard it. Now I'm working with blister packs and narc punch out cards that are locked. Same goes as above. I pull the meds they go instantly into a cup/ syringe and to the clients month or injection site. If refused I discard asap or it goes into their locked drawer until I can discard it.

I'm a newer nurse and I take my time. I'm slower than probably every nurse on the floor with me but it saves mistakes and I never pocket meds. The most I would put in my pocket is a TAR. I go slow, do my checks, and make sure I have no distractions. I've seen some nurses just given clients their meds straight from the blister pack or prepacks and I'm not sure I would practice this way.

As for leaving units with narcotics. I did a stint in a maximum security forensic mental health facility and narcotics that transferred units were locked in a box, placed in a black bag and the transporter had NO KEYS to get into the box, it could only be opened by the receiving unit. Receiving unit had to sign for the med then and there. Maybe those who were asking would benefit speaking to the employer about a system like this? I know its more time consuming but safe guards losing medications!