So I gave a controlled substance to my patient and then decided to straighten up the room before I left ... and promptly (absentmindedly) put the remainder of the ampule in the sharps container without having had another nurse waste it first.
So my options, as I saw them, were either to ask another nurse to "waste" with me ("How much do you trust me?" ), which I don't think is ethical since they didn't actually see me discard the remainder, or to admit to my error. So now I'm waiting for my pee test to come back, missing scheduled shifts since missing drug is a diversion investigation, and hoping that a big organization with rigid policies has room to accommodate honesty about a mistake.
Even though I know the pee test will be negative, I'm becoming paranoid :-). I've been a nurse for 7 years. I have a good reputation with my coworkers and I always try to play an honest game. But I've been thinking about all the things we do, every day, that could look suspicious even when they weren't intended that way.
Example: You pull a narc, get to the patient's room and they no longer want it, and you go from there to a bed alarm and an exploded ostomy and an "oh, whoops, your admit you didn't know you were getting from the ER just arrived" and it takes you 2 hours to get back to the med cabinet to return it. Or you have somebody watch you waste the remainder of a vial with you immediately, before you give the dose, but you forget to go to the computer and waste it with them there.
I would be interested in knowing (from people who are actually working on the floor and know how crazy it can be) what foolproof routines you have developed to keep yourselves absolutely above suspicion when it comes to the daily handling and wasting of controlled substances on the job.
Specializes in Med Surg/ICU/Psych/Emergency/CEN/retired.
Following the facility's polices and procedures will most likely will be the best course. We all know that P&P can differ greatly among facilities though. Since I've done mostly ER, I speak from that experience. The last place I worked we were required to waste only in the med room and only in the locked waste container. No more squirting waste into the sink, toilet or wastebasket. Different controlled meds were packaged differently, sometimes changing monthly. So I had to draw it up into a syringe. It was not always possible to get another ER RN to walk into the med room with me. All RNs might be busy. Crazy to put waste in your pocket, but we did what we had to do. At one time, some RNs would actually tape the unused control drug to the grease board! Yikes. The last ER I worked was the most dysfunctional and partly the reason I left. Overall we trusted each other and tried to accommodate each other asap.
Please forgive my ignorance, but are ratios in Australia that much better than in the US, that policy can be followed that well?
And at least to me, grabbing a witness 'whenever we FEEL like it' is not the way we/I feel about it. However, it simply does not take priority over a code is called/witnessed, or the ambulating patient starts to fall & you catch them instead of immediately wasting.
I am with an earlier poster suggesting you should have just had somebody falsify the waste.
In essence, that's what you do most of the time anyway. When somebody witnesses you dump your open ampule with an unknown amount of an unknown substance, it is really a stretch to call that witnessing a waste. How on earth do they know what you threw out?
In reality, your unit's accepted practice is a farce. Anybody diverting can easily take the unused narcotics, or store them for later use. Nobody diverting is going to claim they accidentally threw it out, they will just put a cc of NS in the vial, and have you "witness a waste" as that awesome Dilaudid rush hits.
BTW- the practice you described is common, and what we do in the 2 ERs in which I am currently working. If somebody is available I have them come into the med room. If not, I walk around with a pocket full of narcotics hoping to remember to have somebody witness it. Nobody thinks twice about it.
Forgive me if this has been said. I would have notified a nurse Manager immediately and have the sharps container removed and locked up until it could be safely opened to prove it was in there.
I have never bothered to have someone actually watch me waste something, nor have I ever bothered to actually watch anyone waste anything. It would be insanely easy to divert at my facility. It's just not our culture to actually watch someone do anything with narcs.
The only time I actually watch is when someone is wasting what's left of a hanging bag of a controlled substance. If I am wasting 2500 mcg of Fentanyl or 100mg of Versed, I am actually curious if that med goes into the sink or not because that could get a whole lot of people high. One morphine syringe? Not so much.
Of course, there's no way to know if that bag's been doctored with, so even witnessing that really doesn't mean anything.
...Just curious, you Australia peeps - who does your witnessing for wasting continuous infusions? You can't be attached to your coworker the whole 12 hour shift to make sure she never drew out 10ccs of Fentanyl and injected 10ccs of NS into that bag, so there's no way to know the bag he/she hung still has the same amount of drugs in it a couple hours or several days later.
Forgive me if this has been said. I would have notified a nurse Manager immediately and have the sharps container removed and locked up until it could be safely opened to prove it was in there.
How would this belp? It would prove that there is an empty ampule in the sharps box.
Yes, best and ideal practice, but you still have to find another RN to come to the med room to be a witness.
It really depends on your facility's culture
...Just curious, you Australia peeps - who does your witnessing for wasting continuous infusions? You can't be attached to your coworker the whole 12 hour shift to make sure she never drew out 10ccs of Fentanyl and injected 10ccs of NS into that bag, so there's no way to know the bag he/she hung still has the same amount of drugs in it a couple hours or several days later.
I'M in the UK but the Australia system seems the same. We double administer most Cd meds. Nurses here on wards don't follow procedure to both to go to the bedside as they are "too busy". But that way leads to errors that can get you into trouble. Our counties infusions are pca bags.that are pretty mixed i guess you could steal from the bag buts it's diluted 20mcg/ml fentanyal or 1mg/ml morphine.
First of all the ampule should have been drawn up in front of another nurse if you knew some was to be wasted, and another nurse maybe could have looked in the sharps dispenser and see some fluid in the ampule, in there, and been willing to sign it. The computer thing you can go back in and fix that. I know how crazy the floor can be, but it's really important to stay at the pyxis or whatever med dispensing unit you use until someone witnesses the waste. After awhile there will be people you can trust if you are real busy. The hardest thing is to find out where the missing dose went when a count is off, so it is best to care of it as soon as you can.
But this is exactly what happens in Australia. It's not hard to find a nurse to follow you for 10 seconds.
i can't fathom how you guys are allowed to pocket remainder of narcotics until whenever you feel like getting a witness. Its asking for trouble and accusations.
We(in the states) are NOT allowed to pocket the remainder of narcotics. Doesn't mean that it doesn't happen, but it's not allowed.
Please forgive my ignorance, but are ratios in Australia that much better than in the US, that policy can be followed that well?
And at least to me, grabbing a witness 'whenever we FEEL like it' is not the way we/I feel about it. However, it simply does not take priority over a code is called/witnessed, or the ambulating patient starts to fall & you catch them instead of immediately wasting.
They very well may be. When there's a census of 35 patients, 6 RNs, 2 PCAs, and it's a Friday (prime discharge day), it may very well be so chaotic that there really isn't time to grab another RN in a pinch to waste. There have been times I poke my head into the hallway from the Pyxis room in search of someone to waste and I may as well see a tumbleweed roll by. Everyone is running around like a nut trying to care for their very ill patients with limited resources. Should my patient in pain wait for me to find a free RN to waste with me? Absolutely not. I'll save the remaining drug and perform the waste later. I will not make a patient wait in pain while I find a nurse to satisfy some stupid policy.
Lol. Overkill to the extreme. Mistakes happen, trusty coworkers know and understand this. 3 hours later if you're stumbling in the hallway and drooling all over yourself, maybe then they would start asking questions.
Should my patient in pain wait for me to find a free RN to waste with me? Absolutely not. I'll save the remaining drug and perform the waste later. I will not make a patient wait in pain while I find a nurse to satisfy some stupid policy.
I guess it comes down to different practices and routines. We have only just rolled out electronic documentation but meds are still kept on shelves/or locked away (CDs). Which is why we also have CD key delagatees. These are people (usual team leader and someone else) who are given the extra task of being a witness and carrying the keys for the CD cupboard. So really, I can't actually even open the CD cupboard without having another person there because that other person will have the key. When it's 8am and the whole ward requires CDs, I only have to wait a maximum of 5 minutes.
Just today, two nurses were doing a CD check in the med room, someone from another floor came and tried asking questions while they were counting. TL saw this and reminded other staff member to wait until after CD was given before discussing something else as mistakes can happen if two people arent watching what's going on. Maybe because I work in Ortho, we're a bit pedantic about pain meds but throughout numerous hospitals I've had pracs on, it's been much the same.
Maybe storing CDs in locked cupboards and delegating a team leader with reduced patient allocation the responsibility of opening CD cupboard and witnessing would help ensure policy is met/reduce mistakes instead of the Pyxis.
At the end of the day, I know there's a lot of rubbish policies that are pointless or not real word nursing but CD administration is pretty important. And if a time comes where you sign someone off when you didn't actually witness them *properly* because you 'trusted them' and now you're in court, like there's no one really to blame except yourselves.
), which I don't think is ethical since they didn't actually see me discard the remainder, or to admit to my error. So now I'm waiting for my pee test to come back, missing scheduled shifts since missing drug is a diversion investigation, and hoping that a big organization with rigid policies has room to accommodate honesty about a mistake.
Boomer MS, RN
511 Posts
Following the facility's polices and procedures will most likely will be the best course. We all know that P&P can differ greatly among facilities though. Since I've done mostly ER, I speak from that experience. The last place I worked we were required to waste only in the med room and only in the locked waste container. No more squirting waste into the sink, toilet or wastebasket. Different controlled meds were packaged differently, sometimes changing monthly. So I had to draw it up into a syringe. It was not always possible to get another ER RN to walk into the med room with me. All RNs might be busy. Crazy to put waste in your pocket, but we did what we had to do. At one time, some RNs would actually tape the unused control drug to the grease board! Yikes. The last ER I worked was the most dysfunctional and partly the reason I left. Overall we trusted each other and tried to accommodate each other asap.