Control of controlled medications

[SolaireSolstice, BSN, RN]

I am doing a presentation about facility implimentation of controls to prevent the loss/theft of controlled medications. I know in many LTC facilities, they use "narcotic boxes" and "pass the keys" and do narcotic counts. (I work in a hospital with e-mar and a Pixis, so forgive my unfamiliarity of this type of system). Does the narcotic count happen at every shift change? What happens if the count is "off"? I've read threads on here about this but I just want to be sure I have the exact scenario down.

[caliotter3]

Every shift change. If you want to see a potential WWIII, just watch what happens if count is off and nobody will take responsibility. If it can be corrected by documentation, then the signatures, initials, entries are obtained. If it is more than that, like a serious discrepancy, then the supervisors and DON get involved and write-ups and consequences come about. At least that is the way it happened in the places where I worked.

[SuesquatchRN, BSN, RN]

It's a huge pain in the rear.

Yes, the count happens every shift change. We count the meds and go against the journal, which you sign whenever you dispense a controlled substance, and which in our facility is a bound volume so pages can't be removed. Both nurses sign off on the count.

If the count is off it depends. If you are over a med, no biggie. If you're short you wrack your brains trying to figure out if you didn't sign for something you gave, you rip the med cart apart to see if you dropped it - I was short a Vicodin last week. I told the DON. If your count is frequently off you're gonna be in trouble.

The narcs live in a safe with an inner and outer door, both of which lock, When they are removed they go into a locked drawer in the med cart.

Offgoing nurse hands off the keys to the oncoming after the count is finished.

You wake up your poor old farts every four hours to make sure their fentanyl patch wasn't stolen from their withered flanks.

[CathyLew]

with our controled meds, the automated system prompts the user to do a blind count every time the cell is accessed. If the count is off, the nurse has a chance to re-count, if still off, it records a discrepancy, that the pharmacy and nurse manager will look into. The system keeps track of everyone that was in the cell, so they ask the person who had the discrepancy, and the person that accessed it just prior.

a last accessed count is done every shift. That means the system only prompts them to count any med that has been accessed on that shift. A full count is done every week--on sundays. To do a count or waste, two nurses have to sign into the MDG drug system.

[SolaireSolstice, BSN, RN]

Thanks for all your help. I have finished the presentation and you guys helped fill in the blanks on the parts I am unfamilar with.

[loriangel14, RN]

We have med carts. Each cart has a drawer for stock meds, a drawer for each pts individual meds and a separate narc drawer.There are no keys, we all have our own codes and the lock has an electric key pad. There is a sign out sheet for narcs with a running total for all the narcs. At the end of each shift we count what is in the drawer and check it aginst what the sheet says. If we come up short we see who is on that narc and ask the nurse/nurses that had those pts if they gave something and forgot to sign it out.It happens very rarely.

[mercy1975]

Every shift change. If you want to see a potential WWIII, just watch what happens if count is off and nobody will take responsibility. If it can be corrected by documentation, then the signatures, initials, entries are obtained. If it is more than that, like a serious discrepancy, then the supervisors and DON get involved and write-ups and consequences come about. At least that is the way it happened in the places where I worked.

I hope some one can help me. New guideliness for the counting of controlled substances came out where you have to count more of the controlled substances. We've only been counting Schedule II. I think you're supposed to do one week out of the month of counting other schedules. How have you been doing this? Any suggestions on the best time, which shift,etc.

Thank you so much for your help!

[CapeCodMermaid, RN]

We count everything at the beginning and end of each shift. All narcotics no matter what schedule, all anxiolytics,sedatives, and hypnotics. If count if off, there is an investigation.

[Nurse!Nurse!Hello?]

We also count at the beginning and end of each shift. An issue I am having is that the narcs from the facility pharmacy are in blister packs, so they are easy to count...but some residents have their narcs delivered from another pharmacy (i.e. the VA patients) and they come in bottles. The problem is that we then have to count out 150 oxycodone tablets, for example. Anyone have a solution to this time-consuming process??

[CapeCodMermaid, RN]

We don't allow ANY narcotics in bottles. All narcotics must be in a blister pack (except of course liquids and patches). If a family brings in meds, we don't accept them. And we tell them that. End of story. I don't even accept regular meds in an open bottle. Who knows what's really in there? I'm not taking chances with my nurses' licenses. Or mine either!

[Plagueis]

Regarding accepting medications in a bottle: there was a situation where I used to work at when a resident refused to take the house stock of a medication, and actually got an order from her physician to have her family bring in a bottle of the medication. It was in a different form (a capsule instead of a tablet). That was the first time I ever heard of that. I couldn't imagine trying to count narcs that come in a bottle.

[Nurse!Nurse!Hello?]

We don't allow ANY narcotics in bottles. All narcotics must be in a blister pack (except of course liquids and patches). If a family brings in meds, we don't accept them. And we tell them that. End of story. I don't even accept regular meds in an open bottle. Who knows what's really in there? I'm not taking chances with my nurses' licenses. Or mine either!

I totally agree with you. Unfortunately, the policy allows us to use meds--including narcotics-- in bottles that are delivered by mail from an outside pharmacy (like the VA pharmacy). It doesn't allow family members to bring in narcotics in bottles that they had filled at a local pharmacy, though.

I think the whole policy is pretty crazy. Once that bottle of oxycodone is unsealed, who really know what's in there? I suppose that someone could take those 150 oxycodone tabs and replace them with a similar tablet, and no one would be the wiser. I wish that there was some law that this policy violated, so that I could have the policy changed. The administration obviously doesn't seem as concerned about it as I am.