What do you do when the narcotic count is off?

[flashpoint]

Last night I went into work and things were going pretty well until we did the narcotic count. According to the narcotic book, one of our residents was supposed to have 28 dilaudid...there were only 26. The pharmacy had just delivered the dilaudid about an hour before shift change...the day shift nurse said that she was too busy to count with the pharmacist, so she just signed the book along with him. She crossed through the 28 that the pharmacist had written and wrote, "Count correction - pharmacist delivered 26 dilaudid, not 28." She then sighed her name and told me I needed to sign after her to resolve the discrepancy. I told her that I would be happy to sign that there were only 26 tablets, but that I had no idea where the two missing tablets were, so I was not going to sign her correction. She then informed me that she is and RN and that I have no choice but to do what she says. I explained that I honestly had no doubt that the pharmacist only delivered 26 tablets (it is a mistake he has been know to make), but since she had signed off that he delivered 28 and since I had no idea where the missing pills were, I was not going to sign. She was obviously angry...her tone seemed threatening. She told me that she was going to call the DON if I did not sign...I told her to go ahead and call because I was not backing down. I tried to call the pharmacist three times and got no answer at the pharmacy, his home, or his cell phone. I also tried calling my DON to see what she wanted us to do, but she didn't answer. I was very comfortable signing that there were only 26 tablets, but I was not comfortable with her explanation. So...she documented in the narcotic book, "Cotjockey refused to sign this count correction, despite direction from RN." The pharmacist did call this morning to say that he found two dilaudid just sitting on his counter...that is where the missing pills were.

Was I wrong not to sign? I really don't want to get in trouble with my DON, but I really, really don't want to get in trouble with the state board...also if there is disciplinary action against one license (LPN), they usually bring equal action against another (paramedic). I worked too hard for both to lose either one or be on probation or anything else. Also, the EMS board is really strict...you can usually get a nursing license back...the EMS board is not so forgiving.

[babiesX2]

I just checked my state board of nursing's Spring quarterly newsletter. Forty three names were listed with disciplinary actions. Two of them are suspended licenses with fines r/t narc discrepancies. When it comes to narcs, I cover for no one. I value my license too highly to risk loosing it for someone else's mistake. Never, ever, never would I sign my name to a narc discrepancy that I did not witness. . . not even for my mother would I do that.

[UM Review RN, ASN, RN]

I was about 99% sure that the pharmacist had messed up...he gets sloppy and does things like that. This nurse is his biggest critic though, so I can't believe she just glanced at the cassette and signed the form. I do feel sort of bad for her though...the pharmacist shows up right in the middle of supper every day and the supper med pass is pretty big. I also know for a fact that this nurse is pretty sensitive to medications...I've taken care of her a couple times when she has been in the hospital, so can't imagine that she would be diverting.

Narcotic counts is one thing that I am very by-the-book about. Very early in my career, I counted narcotics with an agency nurse. While we were counting, I noticed that an entire package of Valium (I know, not a narcotic, but we counted it) was missing. I didn't speak up though because the Valium had been D/Cd, there was no sheet on it, and the pharmacist had been in that day to destroy meds, so I just assumed it had been pulled and destroyed. Nope...it wasn't on the destruction log and the narcotic sheet from the book was nowhere to be found. Now if we having something missing, I check the dectruction log before I'll sign off...it drives people crazy sometimes, but oh, well.

Thanks for the words of wisdom. I was pretty sure I was right, but it's always nice to have a second opioion or two.

Two things:

1) As others have said better than I can, you did exactly the right thing. Never let anyone intimidate you into signing any legal document without it being absolutely accurate.

2) Valium, otherwise known as diazepam, is a benzodiazepine and as such, is a Schedule II narcotic. Here's a link of the gov't narcotic schedule for your perusal.

http://www.nida.nih.gov/DrugPages/DrugsofAbuse.html

[SharonH, RN]

She then informed me that she is and RN and that I have no choice but to do what she says.

So...she documented in the narcotic book, "Cotjockey refused to sign this count correction, despite direction from RN."

Where in the heck did she get the idea that you are supposed to sign just because she is the RN and she directed you to do so? I find this very disturbing. A less experienced nurse might have been bullied into signing. It's good to see that you were strong enough to stand up to her. You have a license and you are accountable for what you sign and she has no right to try to intimidate you into signing after her mistake. I also would not have called the pharmacist or the DON, that was her mess to clean up.

[snowfreeze, BSN, RN]

You did the right thing not signing. You should have called the nursing supervisor and had the count confirmed by that person not yourself.

Your license is first, the facility you work for is a few slots behind that, sanity, comfort, and family needs come way before your DON.

[kat911]

I diasgree with most of what has been said. Whatever happened to teamwork and supporting one another? I, for one would have had no problem signing the corrected count. Do you really think someone would lie about a mere to pills? Nurses need to stick together if we expect to remain a profession. Accept her ansewrs and show her that you respect her by giuving her the trust she deserves. TYou ended up being wrong and she right, didn't you?

This type of team work can get you in a lot of trouble. I see a lot of people ok insulin or narcotic doses without actually checking that the dose is correct. If your name is there as having checked and the dose is wrong, both nurses will be responsible. Theses types of shortcuts/team work are dangerous to the patient. The signing the narc descrepancy report in this case would have been unethical and a violation of the pharmacy and nurse practice act. Cotjockey you were absolutely correct, you handled the situation great! Keep up the good work, our profession need more nurses like you.

[purplemania, BSN, RN]

You did the right thing. Never document anything you did not do yourself or witnessed yourself. When we have a discrepancy a pharmacist must come to the unit and count the meds. The off-going shift cannot leave till the problem is resolved. That is motivation! Most of our units now have an automatic dispenser , so the count is harder to screw up. Not impossible, just harder.