How do you count liquid narcotics?

[Plagueis]

I know that this may seem like an odd question, but this is something that wasn't covered in school, nor in orientation at my current job. I have heard of places that use unit dosing for liquids, which makes it easier to keep track of, but what if the bottle is colored white with no unit doses? If it's, for instance, a 100 ml bottle, and a nurse uses 10mls during a shift, how can one "count" what's left if the bottle isn't clear with measurements on it?

One nurse I asked recently told me that they cannot pour the remainder in a separate measuring container, as it could spill, so she doesn't really measure what's left; she just subtracts what she uses on the narc sheet. Plus, I would think that even with careful use, some of the liquid could spill, as it does when I measure cough syrup (especially if I'm interrupted during a med pass). What happens if one spills some of the liquid narcotic? Basically, what is the correct way to count liquid narcs when there's no unit doses available?

[chelynn]

Actually we had a huge situation in the last place I worked. Hospice does often order liquid morpine for pain or SOB and it come in a larger multi dose bottle. Every one I have ever seen has a clear stripe down it to measure. And they do care very much if it was wrong. We had a count that was 4 mls off and there was a huge investigation into it. Sometimes we would have to twist those bottles around alot and look at them in different light because it is a big deal if the count is off, no different than any other narc count. If you are so signing off in that book than it is your butt on the line if the count is wrong. Don't be nonchalant about it.

[FLArn]

We use Roxanol and Oxyfast which usually are in bottles with a measuring stripe. Depending on whether the nurse uses the dropper provided or a syringe there can be differences in the count. We are allowed a 2 ml leeway. For the large multidose cough syrups with codeine there is a scale on the bottle and we are allowed a difference of the equivalent of 2 doses. We also use injectable Ativan in 10 ml vials and for those it is a "guesstimate"

[ayla2004, ASN, RN]

Actually we had a huge situation in the last place I worked. Hospice does often order liquid morpine for pain or SOB and it come in a larger multi dose bottle. Every one I have ever seen has a clear stripe down it to measure. And they do care very much if it was wrong. We had a count that was 4 mls off and there was a huge investigation into it. Sometimes we would have to twist those bottles around alot and look at them in different light because it is a big deal if the count is off, no different than any other narc count. If you are so signing off in that book than it is your butt on the line if the count is wrong. Don't be nonchalant about it.

pharmacy allows 4 ml unaccounted for out of what size a bottle our liquid meds are either in 100ml or 250ml bottles so 4ml would be allowed by pharmacy. sometimes the problem is as doses are deducted from the tally the wrong figure is entered into the ledger. however sticky liquids do cling when a bottle is nearly empty we pour a little into the lid so that we can syringe up the the dose then return what not needed back into the bottle so a few drops may be lost.

some predose vial do exist for these drug but bottles are cheapar so that what we have.

[Freedom42]

The facility I work at also uses bottles for Roxanol and lorazepam. I wish they did come in unit doses. It would be so much easier all around. Not only is counting a pain -- it's never on the money -- but I question how careful a dose can be when measured with a dropper. How do you make this accurate for administration?

[tewdles, RN]

You have the gist of it...most liquid opioids come in a white bottle with a clear stripe for measuring...it generally has ml embossed on the side. We do evaluate that at each visit and question if the amount in the bottle does not coincide with the order or the stated administration. I rarely have a serious issue with significant discrepancy between what is in the bottle by eye balling vs what I would expect based upon documentation by the nurse or family (yes I ask the family to document doses). When there is a discrepancy it is often explained by a spill (not uncommon in the family home).

I find that the pill form of the meds are more often diverted than the liquid form perhaps they are easier to transport, recognize, and sell.

[skittlebear]

They do make liquid narcotics for those who can't swallow pills as in esophageal surgeries, tube feeders, etc. In the hospital we use unit dose, in LTC you will see it supplied in sometimes up to 300 ml of liquid hydrocodone/apap or roxicodone. These bottles are marked , I believe at every 25 or 50 ml for measurement purposes. Roxanol and lorazepam comes in 30 ml bottles. Both are never accurate measurements, you do the best you can to guesstimate the larger bottles. Just be on the lookout for suspicious amounts being used and signed out. From my experience there is always more in the bottle than what the count says should be. And the liquids are very thick and syruppy so I'd think it would be possible to tell if someone added water to the narcotic to divert. And no you can't pour it out to measure that would be contamination. Hope that helps.

This is what I have experienced as well. I haven't come acrosss a liquid yet that is completely accurate (there is usually more in the bottle than the count should be).

[Not_A_Hat_Person, RN]

I work in an ALF, and I've dealt with Roxanol and liquid morphine. The morphine is in big clear amber bottles, the Roxanol is in a white bottle with a clear stripe down the side. It is dispensed with an oral syringe, and recorded like any other narc.

Counting is pretty straightforward, but we had problems with 1 batch of Roxanol that was clear instead of the usual green. It was almost invisible, making it very hard to count. The count is considered accurate if the amount in the bottle is within 10% of the recorded amount.

[cherrybreeze, ADN, RN]

We have clear orangish-bottles, and it's pretty much a guesstimate, too. It usually is off by a small degree by the time the bottle is empty, and PYXIS gives an option for being off due to spillage, etc for a liquid med.

We don't even lock up or count Lortab or T3 elixir, and this bugs the crap out of me. I've brought the issue forth several times and have been told that there isn't "room in the PYXIS" to store these meds. They are treated like any other liquid med that isn't a narcotic....I'm suprised we haven't been dinged for that practice (yet).

[Plagueis]

Thanks to all of you who answered. I did see a bottle tonight when I was at work of a liquid narc that had measurements on the side of it. However, the lines went in 5 ml increments, but each dose of the med was ordered in 2.5 ml increments, so I guess, like some of you mentioned, that nurses just look to see if the liquid level is about halfway between the 30 ml and 25 ml lines if the previous shift nurse gave a 2.5 ml dose.

It just seems like the "count" can easily be off with these liquid narcotics, so I would think that more places would have unit doses of these liquids, and not depend on guesstimates.