I Lost a Medication: Controlled Substance

  1. 6
    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.
    natnat122, priorities2, JacobJason, and 3 others like this.
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  3. 32 Comments so far...

  4. 4
    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.
    natnat122, cienurse, Meriwhen, and 1 other like this.
  5. 0
    Thanks for the response.
  6. 0
    It happens. Unless you lose them all the time, you should be OK. I once had a morphine drip (about 80-90mg) come up missing from a deceased patient's room. I've also found unopened vials of dilaudid and morphine lying around that other nurses probably misplaced.
  7. 0
    Pangea, thank you so much. I am a little relieved but wont know until I either get a call or go back to work tomorrow. This will definitely not happen again.

    I think when I was tossing the empty wrappers from my pockets, I have a tossed the dose of Ativan with it.

    I was so stressed last night, I got a migraine, I still have a dull ache this morning. I think I feel a little better. I hope I can enjoy this day off.
  8. 3
    I did the exact same thing!

    I had to run and pull the Ativan and other meds from another Pyxis on another unit.
    Somewhere between that unit, another unit I had to pass through and mine, I lost the Ativan.
    Not cool in a psych hospital, with plenty of patients that would just jump on the opportunity to swipe that off the floor and take it!
    I called every unit I passed through and gave them a heads-up that if they found it, it's mine.
    The nurses on those other units were even nice enough to search for it with me when I went back to try and find it.
    I also called the pharm right away and did a report.
    I didn't have to have a drug test-- and nor would I have cared if I did.
    I know I didn't take it.

    I know crap happens, but my worry was that some patient would take it on top of everything else they're taking and it would be just enough to "throw them over", if you know what I mean.

    Anyway, never found it and nothing bad happened (thankfully).

    Now, I always remember that incident, so : I put no meds in my pockets, I make sure there are no holes in the med bags, I use no med bags that don't seal and I obsessively check I still have all my pills until I get my pills where they belong.

    Trust me, you're not the only one!
  9. 5
    Controlled substances going missing is no joke. Yes, you can be fired for this.

    How likely is that to happen? Depends on your facility policy, whether it's currently a problem plaguing your facility, whether you've done this before...who knows? Odds are as it's a first offense and only one dose missing, you probably won't be sacked...you may be written up or undergo other disciplinary action though.

    Definitely offer to take a drug test if asked to, but don't rely on that solely to save your job, as many nurses who swipe meds do so for other people's use or to trade for their desired drug of choice.

    Learn from this. It happens to a lot of people. The secret is not to let it happen twice to you.

    Best of luck.
    Akewataru, cienurse, Altra, and 2 others like this.
  10. 3
    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.
    NRSKarenRN, CP2013, and elprup like this.
  11. 0
    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?
  12. 4
    im sorry this happened to you... ohhhh the pressures of being a nurse... one small mistake, and we feel like our professional life is over... nursing is truly a hard profession... when your trying to do everything right, and make a mistake b/c we're simply human...ugh...
    DeeMari, S.G., cienurse, and 1 other like this.


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