Medication discrepancy

[SammieMom]

Several weeks ago it was brought to my attention by my nurse manager that there had been a discrepancy with a narc I had gotten out of pyxis. I counted 48, took one, count is now 47. The next nurse went in later and counted only 44. She was in a rush, took her two Percocets and forgot about it. (no one else had been in that drawer)

That day the discrepancy was never resolved, I never even knew about it until several days later, because I had few days off. I cannot 100% remember that med removal. I can say without a doubt that I didn't take 4 Perc's out and then give them to my patient. I have NO idea what happened. The nurse who was in pyxis after I was is not only my co-worker, but a good friend. An incident report was filled out and now it has been sent to our risk management.

What happens now?? My friend (the second nurse in pyxis) is not the least bit worried about it. I, on the other hand, am a wreck! I have had discrepancies before, but have always been able to resolve them. I've only been a nurse several years and I try so hard to do a good job for my patient's.

Has anyone else ever had this happen, and if so, what became of it? I would love to hear from anyone with an experience similar to this.

Thanks

Sam:nurse:

[lpnflorida]

Possible causes for the descrepancy can be as follows:

Even though you only took out 1 tablet, did the pixis at that time register two? have seen this happen when we don't change the number from 2 to 1.

Did the excess tablets fall outside the drawer somehow? Have seen this happen where we found them stuck in the carasel part between the drawers. Have found tablets underneath the pixis as they had fallen out when someone was counting and they did not realize it at the time.

These are possible innocent scenarios. The not so innocent I will not go into.

Hopefully, you charted at that time number of tablets you gave the patient in their records.

I had a time where I gave a patient 1 tablet, charted it as such however when initially taking it out of pixis I had failed to catch that it noted the number to be two. The descrepancy was easily resolved in part due to my documentation in the patient's records.

Sometimes, descrepancies are never fully resolved.

While I would have some concern if it were me. I do not think I would lose sleep over it.

You can take to your supervisor if you feel the need to.

[sissiesmama, ASN, RN]

Sammie - Hey! I have been in your shoes before, and I am a little OCD, soo I always stressed over it. Try not to worry too much if you can. As lpnflorida stated in her post, there are quite a few ways the count can be off.

Personally, I have seen -

1. Rph adding 20 tabs and adding 40 to the count.

2. Leaving meds lying on top of the pyxis and not even putting them in the pocket at all

3. One tab wasted r/t falling on the floor

4. Rph adding 20 Percocets and placing them in the Lortab bin

There are so many ways the count can be off. It is a good thing that the nurse following you is a friend, some nurses are petty and will try to set you up. I have actually seen that, unfortunately.

Try not to stress too much. Feel free to pm me if you would like. Have a good evening!

Anne, RNC

[SammieMom]

Thanks so much for the replies. They are all saying the same thing at work, that it could be lots of reasons for the discrepancy...We did check all the drawers in pyxis, thinking they may have fell or got stuck in another drawer. We didn't find them, but I do feel a little better. I did chart how many Perc's I gave my patient, plus in the printout from pyxis it says just one was taken. I just wish I knew of the discrepancy the day it happened. I feel like we would have had a much better chance of finding out what happened.

I'm a little OCD myself, and now you should see me counting Narc's....I feel bad for anyone waiting for pyxis behind me!

Sam

[OC_An Khe]

Like humans machines aren't perfect and they do can make errors. I wouldn't worry about it unless a pattern develops of discrepencies.

[BinkieRN, BSN, RN]

If they didn't ask you for a urine specimen prior to asking you to explain the discrepancy I wouldn't worry too much. Discrepancies happen from time to time. It's the nature of the job. It happened to me and 2 days later the mystery was solved and I was very relieved because I knew I hadn't done anything wrong. I reported the discrepancy the minute I discovered it. The first thing I did was call the pharmacy.