ER Narcotic Waste Procedures

[errn431]

Hello everyone, first time poster/long time reader here.

Looking for some opinions on waste procedures in the ER. I know some of this content has been covered in other forums, but I am looking for specific info.

Background: I am on a patient safety committee work group at a small community hospital in a rural area. We are a 63 bed facility with 14 ER beds. I am the representative on this committee for the ER. Right now we are working on narcotic waste.

Our hospital policy states that once the ordered dose has been administered the nursing staff (LPN or RN) is to place the remaining amount in a clear plastic bag with a patient label and "immediately" take it to the Omnicell and return the waste amount with a witness. I am not advocating anyone not following the policy, but I am concerned that this is not always immediately feasible based on the patient acuity and staffing in the ER.

Our ER nurses have 4:1 patient ratios. We have no CNAs or patient transporters. We have to turn over (clean) our own rooms. We do our own EKG's and nebs. Sometimes we have paramedic who functions in a ER tech role, but we are largely on our own.

It is very challenging at times to have another staff member "immediately" available to witness your waste. Additionally, some times the patient is too unstable to safely leave the bedside as soon as the medication is given.

The Omnicell will not allow you to return without a witness, even as a temporary measure. So the nurse has no choice, violating policy if no other waste witness is available at that moment. Even if a witness is available, the nurse often has to decide between unsafely leaving the bedside of

an unstable patient or either leaving the vial unattended on the counter or placing it in her scrub pocket until it is safe to leave the bedside.

Surely there must be another way that does not risk our patients safety and allows us to follow policy and reduce risk of drug loss/diversion. What does your facility do? What is your procedure for wasting narcotics in a busy ER with limited staffing.

Please excuse any typos, as I am writing this quickly on my lunch break.

[TheCommuter, BSN, RN]

Moved to the Emergency Nursing forum for more replies.

[amzyRN]

We draw the meds up in a syringe and waste in the med room or by the pyxis in front of the other nurse so it can be documented in the pyxis. Then the ordered dose is administered. We don't return waste to pyxis ever. We waste prior to administration it is not saved for later. Pharmacy has made a 0.5mg dose of Dilaudid which has been helpful to prevent excessive waste of medication.

If your facility is worried about diversion, maybe more auditing and more random drug testing instead of a cumbersome practice which you have described.

[R5RN, BSN, RN, EMT-P]

We have two ways of wasting. First is to have another RN present when the med is removed from the Pyxis. They sign into the Pyxis as a witness when the medication is being removed, then you would draw up the dose (or cut the tablet) and waste the rest in front of the witnessing RN.

The other way is to pull out the full dose from the Pyxis without a witnessing RN. In this case, we would just draw up the amount we need and save the rest until we can find another RN to waste the remaining med. There is no time limit on when this needs to be done by.

[Nalon1 RN/EMT-P, BSN, RN]

As the other have said, waste is witnessed when it is taken out, not after. In our Pixys we can waste after, but if you do it too many times, you get flagged and talked to. The only exception is the RSI kit, we can pull that and waste later (or return what is not used).

Besides that the only time I pull and was later is if I am needing something emergent (pt seizing, combative etc). That is rare for me, bu charges do it more often due to floating around.

[Medic/Nurse, BSN, RN]

The 2 nurses at REMOVAL of the med and witnessing waste at that TIME solution WILL NOT WORK at times — for the same reason as the current waste witness issue (lack of staffing @ critical access hospital).

While there are few ideal solutions, I think systems designs is KEY. Pharmacy should stock 2, 4, 10mg Morphine, 0.5, 1, 2mg dilaudid, other opiates in the same manner and the benzo du jour doses should be stocked to minimize waste as well.

Under no circumstance should a nurse leave a dose of a narcotic laying UNATTENDED anywhere with the intend to come back and waste. Just no, nope. Do not.

I also don't really like your system of half used narcs going to pharmacy to be wasted by, most likely a pharmacy tech. Unless these are collected by licensed folks (a pharmacist only) and signed for and reconciled with RN witnesses, on both ends of the delivery to secure area I just don't like it. Color me jaded, but the only good wasted narc is one that 2 nurses watch go down the sink — not stating that badness happens, but when something goes awry the nurse will be guilty till proven innocent. Not the pharm tech collects in bulk in original containers in baggies that can be tampered with only to be wasted down at the pharmacy with less staff than most nursing units.

Now, if these "waste" meds are just stored by 1 use nurse in the 911 "waste-access vault" section of the Omnicell and it takes 2 nurses to sign in to re-open "waste-access vault" of the wasted meds as soon as 2 nurses can do so safely/or when either nurse that has admined a med has to clock out/shift change, that may be the solution. It secures the medication and will solve the waste issue. The med waste can be returned to waste vault without delay and waste can be done as soon as practical without endangering patient safety or compromising controlled substance integrity. This also stops this bulk transport and pharmacy waste of half used narcs.

I watched some antics as a card of 10 Norco went "missing" in a Pyxis. OMG. It was a circus. There had been several RN's in that drawer, a pharmacist and a tech in the last 4 hours. You know who the blame fell on? Ding, ding ding! The nurses! A "for cause" drug test was being arranged through human resources (it was after business hours and they were coming in, if we refused we'd be dismissed for cause & reported to the BON, tho I think pharm staff should have been tested on principle). The police were called. They wanted consent to search vehicles (I refused on principle unless everyone involved was being searched). Lockers searched (belonged to hospital) They requested to search purses and persons (again, unless everyone — pharmacists and pharm techs included — no go for me). A drug dog was summoned from a neighboring department. Not sure what everyone was planning to do with the dog, but I love animals!

Anyway, I never left the sight of the cops or that PYXIS or another nurse. We decided to split 2 of us team observe the lockers and 2 the Pyxis med room. While waiting for HR witch hunt drug RN only drug test, I asked pharmacy that they recount all the carded narcs in PYXIS, "just in cast" as many are similar. After all, they had really stocked it late that afternoon. No one on the RN staff had used any Norco since the stocking. As they were pulling out the main drawer a few times it kept sticking. A card of Norco had been overstuffed in that compartment and likely had slid up and got caught in the main drawer mechanism. Yep. So, there.

Integrity is what you do when no one is looking. The standard you set for yourself is very important.