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Question

How to Reconcile Missing Narcotics

Hello Nurse Beth,

I work the second shift; the 1st shift nurse keeps patients' meds (her shift meds) in a pill box including controlled drugs under their respective names section. At times when I have to give them a controlled drug I am off count because they are in the pill box. According to nursing standard practice for SC state is it proper to include those controlled meds in the pill box in my count since they are unidentified?

Dear Missing Narcotics,

The BON in any state would sanction this nurse's behavior, and the Department of Public Health would investigate any facility allowing this practice. If you attempt to reconcile narcotics by counting pills that are not there… you are also complicit.

Narcotics should be removed at point of administration, and not ahead of time. Do not count drugs that are not properly packaged and locked up in the narcotic cabinet or wherever the designated place is.

Basically, the first shift nurse is removing narcotics without signing them out, which is wrong, if not diversion. This of course is causing a discrepancy in the narcotic sign-out record (I'm assuming you use a paper sign out sheet because you didn't mention overrides in Omnicell or Pyxis, but the principle is the same).

My question is, why are there unidentified narcotics in the pill box after she leaves? Did she pull narcotics, remove them from the packaging, and then not use them during her shift? Are narcotics not counted together at change of shift?

What you need to do when faced with a narcotic discrepancy is to follow your facility's procedure regarding discrepancies. You must immediately notify the Supervisor and Pharmacist that there is a discrepancy. Do not attempt to reconcile the discrepancy by counting/retrieving pills from the pill box or anywhere outside of the designated cabinet. Simply write down the number of pills you find before you remove a pill, and the number of pills you remove.

It's not your job to fix it, and there is no way you can. Hope this helps.

Best,

Nurse Beth

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    This, to me, is reprehensible, unethical and illegal. Nurse Beth has it right...when the count is off, call the Supervisor and Pharmacist. You don't need the trouble this can bring you!

    Good Luck!

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    No way, Jose. I understand why the other nurse might do it, but to take out something that is not his/her responsibility to give is dumb at best. The possibility for those narcotics to later disappear is a real danger and then it will fall on you. You aren't the one who's taking a dangerous shortcut; the other nurse is. To provide documentation that you know is wrong and yet leads right to you is just plain stupid.

    If the count's wrong, report it as such and let the chips fall as they may. They will figure out what's happening and the other nurse will either be counseled or fired. Unless there's an ongoing problem with missing narcotics, my money is that the other nurse won't be fired but will be given an opportunity to change his/her practice to something more acceptable.

    Let me throw out one other warning out there for new nurses: some of your coworkers may be downright evil. Never ever leave a Pyxis without logging out. I know of cases where narcotics were diverted in that way and even worse, where narcotics were taken and then immediately disposed of down the sharps box or down the toilet. The intention was to create a miscount with a paper trail leading right back to the nurse who didn't log out. It's a good way to get somebody either fired, in a jam with the BON, or both. Don't let it happen to you. Always log out.

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    It shocks me that in this day and age somebody would do this. Am I right in assuming this is an LTC facility where there is no automated system or is this nurse falsifying the system?

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