I need help...keep forgetting to waste narcs

[BabyLady]

I work in a unit where we don't administer opiates or other meds that need to be wasted every day, in fact, you can go a couple of weeks and not administer any.

I never, ever administer a med without getting an employee to witness the waste and watch me put the remainder in the sharps box, sink, whichever is closer. Our facility doesn't care which.

However, our system doesn't "count" it, until you both go to the computer and put in your passwords together at the same time...it allows you to take the med out, but you are expected to enter this into the computer before you leave at the end of the shift, or a report goes out to your boss that you missed the waste.

I cannot, for the life of me, remember to do this and I need suggestions from others of what I can do. The chaos of report, shift change and just being exhausted after 12 hours...I end up remembering about two hours after I have left or when I get an e-mail from my boss.

It happened again a few days ago, and I set an alarm on my cell phone to "buzz" me via vibrate about 30 minutes before shift change, so I don't forget, but for some reason, it didn't go off.

I wished the system wouldn't allow you to clock out without wasting the meds, but obviously, it doesn't because the med system and the time clock are not linked.

Is there ANYONE with a creative suggestion to help me remember??? I'm at a loss.

[kaliRN]

Originally Posted by brownbook

"Hi, there are a lot of good answers, but maybe until you can get the whole computer, waste sign out, thingy changed you could just get a thick rubber bracelet. When you take out a narc you will need to waste put the bracelet on over your sleeve or up high around your biceps. When you are ready to go home this could remind you "oh yeah I need to waste my narcs." (Like tying a string around your finger.)"

Originally Posted by BabyLady:

"I actually like this idea...or something similar to it"

BabyLady, I do not mean to be rude or harsh, and sometimes Internet posts are interpreted poorly, so I want to make that clear ... But I am curious why of all the responses so clearly demonstrating the liability you are placing on your license, your job, and your reputation - that you still only want a "reminder?"

Not being accusatory, I am a new nurse myself, so I am trying to rationalize your hesitations. Is the environment so inhospitable you feel like you would be jeopardizing your position if you spoke up? Is it not in your nature to question policy or be assertive with fellow nurses? Perhaps if you shared why you had such a hard time asking these nurses to waste with you at the computer, someone with experience could help you consider your approach.

[brownbook]

Kali RN, it is almost sad that you have to so delicately phrase your questioning of our advice. I appreciate the way you stated your question.:)

I worked with a computerized drug system 5 years ago. I really can't remember the details, but it seems obvious that if the doctor orders 50 mcgs of fentanyl every 5 minutes up to 200 mcgs. Then when you sign out a 100 mcg vial of fentanyl you have no idea if you are going to be using the full amount or be wasting. I think the option was to enter yes or no when the screen would ask do you plan to administer the full amount of this drug. I guess we would put no???? Then the problem of having to remember to waste it if we didn't give the full amount.

I work in a free standing independent out patient clinic. We don't have computerized anything! We have a sheet of paper with all the narcotics names pre-printed at the top. When we need a drug we write down the patients name, our name, name of drug, and amount given, amount wasted. Again a RN has no idea when she signs out the drug if she will use the entire amount or waste some. We just leave the amount given blank. And again the problem of remembering to come back later and fill it in and have someone co-sign the waste if there is any.

Every day we start a new sheet, and every day there are post it notes with nurses names to please sign out your waste from yesterday. It isn't the greatest system, but there is never any huge deal made about it, never any threats that someone is diverting drugs or going to lose their license or the state licensing board is going to close our clinic.

[morte, LPN, LVN]

Kali RN, it is almost sad that you have to so delicately phrase your questioning of our advice. I appreciate the way you stated your question.:)

I worked with a computerized drug system 5 years ago. I really can't remember the details, but it seems obvious that if the doctor orders 50 mcgs of fentanyl every 5 minutes up to 200 mcgs. Then when you sign out a 100 mcg vial of fentanyl you have no idea if you are going to be using the full amount or be wasting. I think the option was to enter yes or no when the screen would ask do you plan to administer the full amount of this drug. I guess we would put no???? Then the problem of having to remember to waste it if we didn't give the full amount.

I work in a free standing independent out patient clinic. We don't have computerized anything! We have a sheet of paper with all the narcotics names pre-printed at the top. When we need a drug we write down the patients name, our name, name of drug, and amount given, amount wasted. Again a RN has no idea when she signs out the drug if she will use the entire amount or waste some. We just leave the amount given blank. And again the problem of remembering to come back later and fill it in and have someone co-sign the waste if there is any.

Every day we start a new sheet, and every day there are post it notes with nurses names to please sign out your waste from yesterday. It isn't the greatest system, but there is never any huge deal made about it, never any threats that someone is diverting drugs or going to lose their license or the state licensing board is going to close our clinic.

perhaps this because they dont know any better? only one dose is to be used out of any one vial....the rest wasted, sign out new vial for next dose.....really, very simple.

[brownbook]

Morte, thanks, maybe we are doing it wrong!

So the order is 25 mcg fentanyl every 5 minutes up to 200 mcgs. So I fill my syringe with 100 mcgs of fentanyl, waste 75 mcgs, with a co-worker, inject 25 mcgs. Repeat every 5 minutes? Is that how we should be doing it? Seems I could easily be wasting 600 mcgs of fentanyl if I give 200 mcgs. Seems a little tedious, wasteful, and time consuming?

[kaliRN]

Thanks brownbook, I think it's important that I don't speak from experience I don't have when I offer opinions.

I think the difference in viewing the orders and methods for carrying out narcotic administration may be the type of facility you are working in? What I have seen, to avoid the waste and time-consuming method you are describing that order would be converted to a drip or IVP q1hr. With only the loading dose (50-100 mcg q 10 min prn assess 2 hrs) to be administered from separate vials (so yes, if 50 mcg, then 50 mcg get wasted). If the pt was experiencing relief, then you go to 25-100 mcg IVP q1hr, unrelieved, convert to drip per protocol.

[brownbook]

Kali RN, your idea is great, except it is a small out patient surgery clinic the patients often are ready for discharge in 1 - 2 hours. We don't even have IV pumps. Welcome to the stone age!!!!!

[kaliRN]

Brownbook,

The stone age comment made me laugh. I could tell from your previous post that the setting probably precluded doing a drip or something similar. What I can say, is that what you are describing sounds very different from the protocols for an acute care facility (where the OP is likely working). If you are using narcs like Fentanyl for sedation, than the protocol is different. Perhaps I am off the mark here, but I've spent some time observing same-day and ambulatory care nurses, and their administration practices are very different. A nurse couldn't be there to waste every 5 minutes of administration and then leave to care for another patient (and then you have another issue if a combination of 2 opiate drugs were being used Fentanyl/Demerol for example). Generally, the entire vial is drawn up, one nurse is administering - another is the procedure nurse, any waste is done when the procedure is over. I suppose that makes the difference (the narcs are never "out of sight" of the person signing the waste). That might not be what you are using it for, I just give the example to say while wasting with another nurse is standard, using a new vial each dose may not be.

If policy and procedure protects the nurse and is in line with governing bodies and is being followed, then there is not a threat to one's license. (Which may be the case for you.) I just think, the OP might be ignoring advice out of fear of "stirring the pot" because of the culture in her hospital. That would be a shame. Thanks for humoring a new grad (and being so respectful).

[BabyLady, BSN, RN]

I just want to clarify a few things.

First, I just want everyone to assume, for a minute, that I'm not a complete idiot. Tons of people on here are posting advice as if I'm too stupid to comprehend the concept that wasting needs to be done.

If I thought that, I wouldn't have posted the question at all.

ALL of our narcs, because of the way our unit is set up, leave the sight of the person witnessing the waste...always. When you pull the drug out of our pyxis, it's out of the room and down the hall from where our patients are and no one sees you take the drug out. You take it to the patient room to scan the med into the computer system to match the drug to the patient...YOU DO NOT WASTE THE MED AT THIS SAME COMPUTER....you have to go back to the pyxis, which is attached to another computer, and have to waste it there, which is again, a trip down the hall.

Because of the way our NICU is set up, you are in a room with 6 babies and one other nurse. You cannot leave the room unattended. So if I get, let's say Morphine out, I bring it into the room...the other nurse never saw me take it out of the pyxis...I bring it over to her and say, "I'm supposed to give 0.3 ml"...she never looks at a computer to verify what I tell her is correct...she takes my word for it...she watches me push out the 0.7 of the oral syringe, then I walk away to give the correct dose to my baby in the same room.

Then I have to wait for her to get finished with her feeding/assessment, etc and get her to go down the hall to waste the med in the computer attached to the pyxis....I stay in the room with the patients.

That is how it's set up.

Now you know why most wait until all of your opiates are given for the shift before recording the waste in the computer.

I have asked nurses witnessing the waste to record it...I can't make her get up and go to the computer to do it, but yet I'm the one that gets into trouble if she doesn't.

[kaliRN]

Originally posted by babylady:

"First, I just want everyone to assume, for a minute, that I'm not a complete idiot. Tons of people on here are posting advice as if I'm too stupid to comprehend the concept that wasting needs to be done."

I cannot speak for other posters, but I know I continued posting to clarify the issue, not to attack your intelligence. I think its possible that most if not all of the posts are out of concern for you - not attempting to assume your incompetent.

"That is how it's set up.

Now you know why most wait until all of your opiates are given for the shift before recording the waste in the computer.

I have asked nurses witnessing the waste to record it...I can't make her get up and go to the computer to do it,

but yet I'm the one that gets into trouble if she doesn't.

"

Your posts were clear to me, while having the Pyxis out of sight of the other nurse is not the primary issue, because you are presenting the vial to the nurse unopened when you waste ... Having to record the waste there is. The point a lot of these posts is trying to make is not that you are not wasting meds in an appropriate manner - because you are. It is that if it's not documented it didn't happen. If you need to waste at the second computer where you draw up the med, if you need to waste the med in the room with your baby(ies), then it should be set up so that you can do that. There is no reason you should have to lose your license because you have to walk down the hall - which clearly is not a possibility. Change the system - not just your practice. It would as simple as making the computer used when you are administering medication a mobile computer (the type of wheels). Both nurses get to do things the right way, verify the order - verify the dose - verify the waste - and document.

This is not an issue of you being an idiot, not understanding the nature of wasting medication, or having a problem with memory. The problem is the way your hospital has things set up - and the advice offered is suggesting that you address this with the appropriate staff members at your facility. The very last words you type say it all, I truly believe you got so many responses, because other nurses are concerned for the "trouble" you may cause yourself by wasting this way.

[Meriwhen, ASN, BSN, MSN, RN]

Tons of people on here are posting advice as if I'm too stupid to comprehend the concept that wasting needs to be done.

Well, if you didn't want all this advice, then you shouldn't have posted the question because you're only getting what you asked for :)

I also agree with kaliRN that most responses here aren't out to question your intelligence but rather to help you protect your license. Whether you want that help or not...well, that's up to you--it's your license, not ours--so feel free to consider or ignore posts as you desire.

But should something finally happen with these narcs and lack of proper documentation, it's safe to say that your facility isn't going to go to bat for you to save your license. And that's the concern you're seeing. Most of us think you and your facility needs to be proactive about change so you don't get into trouble...and if the facility won't change then you need to do what you can to protect yourself.

[morte, LPN, LVN]

I just want to clarify a few things.

First, I just want everyone to assume, for a minute, that I'm not a complete idiot. Tons of people on here are posting advice as if I'm too stupid to comprehend the concept that wasting needs to be done.

If I thought that, I wouldn't have posted the question at all.

ALL of our narcs, because of the way our unit is set up, leave the sight of the person witnessing the waste...always. When you pull the drug out of our pyxis, it's out of the room and down the hall from where our patients are and no one sees you take the drug out. You take it to the patient room to scan the med into the computer system to match the drug to the patient...YOU DO NOT WASTE THE MED AT THIS SAME COMPUTER....you have to go back to the pyxis, which is attached to another computer, and have to waste it there, which is again, a trip down the hall.

Because of the way our NICU is set up, you are in a room with 6 babies and one other nurse. You cannot leave the room unattended. So if I get, let's say Morphine out, I bring it into the room...the other nurse never saw me take it out of the pyxis...I bring it over to her and say, "I'm supposed to give 0.3 ml"...she never looks at a computer to verify what I tell her is correct...she takes my word for it...she watches me push out the 0.7 of the oral syringe, then I walk away to give the correct dose to my baby in the same room.

Then I have to wait for her to get finished with her feeding/assessment, etc and get her to go down the hall to waste the med in the computer attached to the pyxis....I stay in the room with the patients.

That is how it's set up.

Now you know why most wait until all of your opiates are given for the shift before recording the waste in the computer.

I have asked nurses witnessing the waste to record it...I can't make her get up and go to the computer to do it, but yet I'm the one that gets into trouble if she doesn't.

ah ha! your "physical plant" is totally inappropriate! your explaining the lay out goes a long way to delineate your problem.....this is one of those system problems that is talked about.....needs to be corrected. The ability to do the "waste" at the time of dispensing needs to be provided.....this is where the action needs to be applied. Try contacting your risk management dept. good luck