How Do You Sign Your Narcotic Book?

[flashpoint]

Currently, my facility has one page for each bubble pack. When we give a narcotic, we sign our name, date, time, the current number of tablets (patches, vials, etc.), the number we are taking, and the number remaining. At shift change we sign one for saying that we counted all of the controlled substances and that the count is correct. In the few months I have been there, there has not been a discrepancy. Policy states that if there is a discrepancy, we don't sign, notify the DON, and she investigates. In the six years that she has been the DON, she has always found a logical explanation for each discrepancy.

Our nurse consultant wants us to sign each individual page at every shift change to verify that the count is correct. We would also need to write in the date, time, and correct number of tablets or whatever. I tried it today and it took over 20 minutes. When they are concerned about overtime and the system we are currently using works, making a lot of changes doesn't seem to make sense.

How do you do it?

[NutmeggeRN, BSN]

Each shift, every page is reviewed, the med is counted and verified and there is place in the back of the book for the date time and signature of both the incoming and outgoing nurse.

It seems as though there is an increased chance for a page to missed, thus increasing the the possibility of an "error" depending on how your policy views them.

[CoffeeRTC, BSN, RN]

We do it as you described. One page per med. Started when you get the med and just signed off with each does. We then have a page at the start of the book/ binder that we sign on at the start of the shift and off at the end of the shift. Each nurse has a spot.

I might have at least 20 or more different carts, boxes of patches, injectables or liquids on my cart. I couldn't imagine doing all of that double charting. Is this a pharmacy consultant or nursing? I'd want to see the reg or back ground for the new requirement.

[NutmeggeRN, BSN]

We do it as you described. One page per med. Started when you get the med and just signed off with each does. We then have a page at the start of the book/ binder that we sign on at the start of the shift and off at the end of the shift. Each nurse has a spot.

I might have at least 20 or more different carts, boxes of patches, injectables or liquids on my cart. I couldn't imagine doing all of that double charting. Is this a pharmacy consultant or nursing? I'd want to see the reg or back ground for the new requirement.

Or the evidence that proves this is a best practice!

[flashpoint]

It is a nurse consultant. Our pharmacy consultant says that our current policy is fine. I am pretty big on asking to see the regulation when there is a change in policy that causes more work. The DON asked to see the regulation and the consultant just looked at her the way I look at my kids when they asked questions like why dogs bark instead of mooing or meowing.

I do know that a lot of facilities in my area do the sign every page thing. I want to know why and I want to see the documentation that says we have to.

[wanderlustnurse88, RN]

We did the sign every page for a while when we switched pharmacy. Now we have a page (usually 3 or 4 pages) at the front that we sign each count. We have an individual page for each medication.

[Elladora]

Unfortunately we do it the second way you describe. Each time we give a med, we have to write in the starting count, the dosage given, dosage wasted, end count, and our signature.

At shift change, same thing, one page for each med.

Signing narc count takes 20-30 minutes of my shift.

[txbornnurse]

When I was doing nurse consulting for LTC pharmacy services we never recommended that each shift sign off on each individual count sheet plus a shift change count sheet. Double documentation is rarely a good idea. All that the regulations require is that each individual medication be labeled and stored correctly, that each dose of a controlled substance be signed for individually, documented on a MAR of some type and that at shift change the total number of controlled substances be counted and the verified count be signed off on by the oncoming and the outgoing shifts.

There have been arguments made that the additional signing is a good way to verify that each medication container of controlled drugs was actually counted and verified by the shifts. In reality it does no such thing. If folks want to fake it they can if both shifts agree to turn a blind eye to proper and Federally required accountability procedures. What the redundant documentation does is add more time to an already time consuming process depending on the total number of controlled drugs per cart or med room fridge and leads to chances to miss individual count sheets.

I did a narcotic diversion investigation at a facility that did this additional procedure plus initialed by each bubble pack. Did nada to help me discover who, how and when the diversions occurred. IMO your nursing consultant is incorrect.

[NutmeggeRN, BSN]

I did a narcotic diversion investigation at a facility that did this additional procedure plus initialed by each bubble pack. Did nada to help me discover who, how and when the diversions occurred. IMO your nursing consultant is incorrect.

Signing the bubble pack, what a pain in the butt!!! Effective to catch a missed dose maybe? Anyone can pop out the pill(s) and sign that they gave a Tylenol or any other drug and pop it into the trash or sharps container. Means nothing to me. What about when bottles are used (from brand new patients who are using up med inventory from a mailaway Rx), why not sign the Maalox bottle, or the box the Fentanyl patches come in??? A lot of double documentation is not efficient.

But in our system (in another building) I have heard there are MNAs who have packed in clear envelopes, narcs by 5's in order to shorten the time it takes to count.....

No bueno...

[Sadala, ADN, RN]

I was reading OP's post and thinking, "Wow. That's cumbersome..." Then I realized that really, I guess we do the same thing with a pyxis.

You know, put an accurate count in, then scan the medication, have any waste witnessed by another nurse, and then at the end of the shift have a nurse from each shift count and enter the count on the narcs into the pyxis.

I guess it is a lot faster though, not having to hand write it.

[Sadala, ADN, RN]

But in our system (in another building) I have heard there are MNAs who have packed in clear envelopes, narcs by 5's in order to shorten the time it takes to count.....

No bueno...

Ha! I don't do that. But when I read your post it reminded me... I was a clerk for a time and when I counted change I would count by five's. It was just easier to group the change by five's in my mind and get an accurate count. I find I do the same thing now when I have to count narcs.

Except sometimes they have narcs explicitly packaged in groups of four or ten so obviously I switch it up. But with singles, I still always count by five. Just funny the habits we learn.

Where are you working that you have a cart and paper MAR. Is this Rehab or LTC or?

[CaringGerinurse525]

We have a narc book with an individual sheet for each narc that we sign when we give one of that narc. Then we have a sheet with all the narc bubble packs listed on and write the final count for each at the end of shift. Only takes a minute to fill out. Almost all of us sign the bubble when giving a narc. Has saved us errors by catching a narc missed but still in timeframe to be given or when one nurse gave too many it could be proven because she signed and dated it.