Narcotics missing

  1. 0
    I have been a psych nurse for some time, but was in a paperwork job for 3 years, and out with babies for 5 years before that.

    I recently was hired by a psych hospital. Last week was my first week, after orientation. The floor I was put on had 35 patients, two RN's and 3 tech's. We had many very acute, some suicidal, and several elopement risks. On an average evening shift: we got on different days: 3 admissions to 7 admissions. Dr's were rounding past 5pm, and there were new orders on at least 10-12 charts (unflagged).

    All that to say: There was a narcotics count error. Two RN's using the cart, but other RN has been at hospital a good while. TWO narcotics missing. Absolutely insane! And there was not accounting for it! I do know, at HS on that floor, we hand out Ativan, Ambien, and Klonipin like it is candy to 90percent of the patients (per orders). I think somehow there was a med error, (wrong drug given to a patient) but we could not find it. We both stayed 2 hours with the shift supervisor, looking for the errors. None could be found.

    I wrote up an incident report, we notified all the people who needed to know. In hind site: I should have asked for a urine drug screen, we do them routinely there on patients....but I was too tired (1am) and too scared to think of that.

    In giving meds, because they have an old fashioned system of giving and charting meds, and signing them out. (no pixus)....I find myself very nervous, and checking, and double checking and triple checking. So I really do not see how I could make that error, except for true nervousness.

    I called the shift supervisor today, and said I wanted to address it straight on, and what was the protocol for what would happen next. She said there is no protocol (yet) new hospital, but that the DON is looking at it. I said I had some suggestions on ways to improve their narcotic holding and signing out (even without a Pixus). She laughed and said that no, they were going for the big guns like a camera in the med room. I said Great!

    But I now am sitting at home, worried to death....I don't work until 2 days from now, and have been sick about it now for 2 days. What to do.? Anyone been there? I have NEVER had this happen before, and No, I did not take the two missing narcotics. I did notice that they are very lax about propping the med room door open, and leaving the keys in the top drawer. So what to do? I really do not know!!!!

    Please advise! I am paralyzed with fear about what might happen to me. (once they decide). Or put a blemish on my license.
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  3. 10 Comments so far...

  4. 3
    Doesn't sound like your boss is concerned. Let it go. I've had narcs missing and it wasn't a big deal. It also doesn't happen often.
  5. 0
    Not a big deal?? I worked for several years as a hospital surveyor for my state and participated in some surveys where we found narcotics discrepancies in doing the routine chart reviews, which the hospital hadn't caught or bothered to investigate and resolve (if they did catch it) and let me tell you it sure was a "big deal" once the state licensing agency and DEA got involved ...

    I agree, though, that if the facility doesn't care about tracking down and resolving the problem (and following appropriate protocols with controlled substances to begin with), there isn't much an individual nurse can do.
  6. 0
    Quote from elkpark
    Not a big deal?? I worked for several years as a hospital surveyor for my state and participated in some surveys where we found narcotics discrepancies in doing the routine chart reviews, which the hospital hadn't caught or bothered to investigate and resolve (if they did catch it) and let me tell you it sure was a "big deal" once the state licensing agency and DEA got involved ...

    I agree, though, that if the facility doesn't care about tracking down and resolving the problem (and following appropriate protocols with controlled substances to begin with), there isn't much an individual nurse can do.

    If once a month an Ativan is missing is that a big deal? That's what I'm talking about, not boxes of Fentanyl patches and packs of Vicodin going missing.
  7. 4
    i worked for several years in a state psych hospital -- as a staff nurse, charge nurse and, finally, as supervisor. i began in the era when the drugs were dispensed from bulk bottles of 1000, through the era of unit dose blister pack individual doses. i firmly believe there were many many fewer errors, when the meds came in the huge bottles because the pharmacy staff as well as the pharmacists themselves, simply had to much to do when unit dose packs began to be used. the old system put much more pressure on the meds nurses, but we usually seemed to make many many fewer meds errors. there were as many tabletsand pills to pass but not nearly as many kinds, if that makes any sense.

    if just an occasional med remained unaccounted for, after a thorough investigation and search, it was not a reflection on the nurse on that shift, but if the same nurse were working on most of the shifts where the irregularities occurred, then there was a full-blown inquiry and a drug test of that nurse.

    your supervisor isn't upset, so don't panic. if i sound as though i'm taking it lightly or blowing it off,
    believe me, i'm not. when i would get really upset as a kid, my mom used to tell me not to get upset until i was absolutely positive there was really something to be upset about.

    kathy
    shar pei mom
    ohmeowzer RN, nursel56, abundance56, and 1 other like this.
  8. 0
    Quote from SuesquatchRN
    If once a month an Ativan is missing is that a big deal? That's what I'm talking about, not boxes of Fentanyl patches and packs of Vicodin going missing.
    I'm talking about one or two doses, not large quantities. State and federal laws don't allow for any acceptable "margin of error" with controlled substances -- the facility is reponsible for accounting for every dose. Facilities that consider "close enough" to be good enough are just gambling that they're never going to get caught.
  9. 2
    you did the right thing. you did an incident report. you didn't take it. If you did your urine would be dirty for 30 days. Take some deep breaths and take it easy. Try to be careful next time when giving the narcotics. I understand how busy it gets. It could have been someone else's error.
    dance4life and sharpeimom like this.
  10. 1
    i thought i was the only one, but that had happen to me too.... we also have narcotic missing and it happen on my shift... missing two tabs narc... i pick up and wrote an incident report and has of right now they are still investigating and it seems like the blame is on me, and whom ever took it is still out their, so i really wish this person shouldnt done this because my license is on the line, and i dont want anything to ruin what i worked hard for... reporting it off was the idea and the right thing to do, that i had in mind, because this person has to know that this habit has to STOP...questioning and explaining what happen, but main point two tabs of narc are missing and still looking for it... God willing this person comes forward and say something, i just worried what will be the next to come for me, im still young and becoming a nurse is my dream, to care and help so that someone would be able to thank you later...


    heart broken of what has happen, praying God to guide this through and hope for the best...
    dance4life likes this.
  11. 0
    I hope what you are going through is "okay" now.

    I am a Traveler/Agency nurse for the past 6 years. I usually don't make clinical mistakes. First time I had a bad orientation with no computer orientation. So I winged it. Complained to my agency about it that due to their lack of computer orientation I could make a clinical error. Now there are 4 narcotics missing that they say I documented as "not given". Huh? Not sure if they are all four, just one, maybe three, who knows? My agency isn't giving me any documentation details as to which narcotics; just that I must of made some documentation error and oh that the BON and DEA will investigate. I called the BON myself to see what will happen to me because, of course I have to leave the housing within 48 hours and I was worried how will the police find me if we are homeless. (I travel with my family) They explained it could take months or years. That was kind of strange to me because, I have heard stories of nurses getting arrested in their home. Correct me if I am wrong here. Honestly, I have no idea what I did and of course it is an awful feeling when you make a mistake, and when you get accused for something you didn't do. Honestly, if I had money after I didn't get the training I would of left right away. It really would of avoided this error. Goodness sometimes I miss paper charting. So of course I am getting an Attorney, taking my drug test for the agency, and I am going to my own physician too for my own record. Man, I don't even feel like being a nurse right now. Some of the stories of jail time scare me. I didn't become a nurse to go to jail.

    It also is great timing I didn't renew my insurance because I was in between assignments, broke, and what have you. Get that insurance by any means possible. I wouldn't wish this on anyone.
    Last edit by dance4life on Oct 2, '13
  12. 0
    We have 2 Omnicells on our floor, we count every 12 hours and we have a discrepancy probably at least once a week. No one is stealing, some of the nurses just need to retire. I've never heard a single thing about it, we just resolve discrepancy in Omnicell and move on.


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