Missing Ambien

CT Pixie, BSN, RN · May 9, 2010

I'm a little confused. You did the narc count with the 3p-11p nurse, the count was correct, the book signed off by both you and that nurse and keys handed over..am I correct so far? Then the NEXT day (2 full shifts later) the 3p-11p super was asking you about that med? Is it that the count was off from the 3p-11p handing off to the 11p-7a nurse? The 3p-11p nurse wasn't sure if she had given the ambien even though she signed if out of the narc book and signed off the MAR? How can that be YOUR problem? I fail to see why they would point a finger at you, if SHE is unsure if she gave it or not..and if she didn't, wouldn't she be responisble for the "missing" bubble?

I am under the impression, that you did the narc count and the oncoming nurse counted with you. She accepted the narcs when she took the keys and signed off that the count was right. I can't see it coming back at you. I don't see anything can "happen".

I did a narc count one shift. I signed off and accepted the keys. later that night as I pulled one of the meds from the narc drawer, I noticed that one of the bubbles toward the middle bottom of the card was empty. Thus really having an incorrect count. i notified my super, we both inspected the card. It had no signs of tampering. It just happened that when the pharmacy filled the bubbles, they missed one. Which is easy enough, these are 1/4 of a pill that is a small pill to start with.

so in reality, the count was off from the start when we first accepted the med in house. Instead of 60, it was really 59. Certain people wanted to point fingers at this one or that one, but EVERY single nurse on every singel shift had missed that empty bubble. In the end no one was "spoken to" or disaplined. It was an honest mistake, there was no diverting of meds. Lesson learned, I always take the card out and make sure each and every bubble has a pill in it.

scoochy · May 9, 2010

CT Pixie is absolutely right on this one!!!

Hospice Nurse LPN, BSN, RN · May 9, 2010

You both counted the narcs and signed the book. There is no reason they should be questioning you after 2 shifts!

Meriwhen, ASN, BSN, MSN, RN · May 9, 2010

I work 7-3 shift in LTC. Last Thursday I counted narcotic at the end of the shift with the 3-11 nurse, we signed the narcotic book, and I went home. When I came back the next day at 7am the 11-7 nurse told me that 3-11 nurse missed a bubble of ambien last night. I checked the narcotic book and she signed out a tab. at 9 pm because resident get this med once a day at 9 pm, also she signed in the MAR that she gave the med at 9 pm. The 3-11 supervisor came to me and with an accusatory tone asked me about the medication, because she said that 3-11 nurse told her that she is not sure if she had the medication. what do you do in my case?

If the narc count was correct at the end of your shift and 3-11 signed for it, then there's nothing they can do to you. Any discrepancy is now the responsibility of 3-11 and NOT you, because it had to have happened on her shift.

If the Ambien count was off on your shift, then 3-11 should have caught it when she counted with you. Then the missing Ambien would have been your fault, and it should have been addressed with you before you left and she took over, and not waited two shifts. She also should not have signed for it if she knew it wasn't correct.

But if 3-11 didn't actually count the pills and just said "yeah, it's there," as you and her went through the narc book, then it is 3-11's responsibility because she should have actually counted the medication.

They can't blame you for this one: 3-11 needs to keep better track of her narcs and/or count them properly. Tell the 3-11 supervisor that 3-11 counted with you and the count including the Ambien was correct before you left, and that's all you know about the matter.

However, for your own protection, you should make it a habit to physically count each pill at shift change, regardless of who's the offgoing nurse because errors happen to the best of us. Likewise, be sure to count each and every bubble: in addition to the missing-pill-yet-sealed bubbles, I've also had the two-narcs-in-one bubbles. I once had one card with one empty bubble and one with two pills in it, so the count always worked out to match the bubbles. When finally discovered, we told pharmacy ASAP so it could be corrected.

And also get into the habit of checking the count after you give a dose if possible...not always possible in a busy LTC, I know! But at least you'd be able to catch a discpreancy right away.

SillyRN_CEN · May 10, 2010

I work 7-3 shift in LTC. Last Thursday I counted narcotic at the end of the shift with the 3-11 nurse, we signed the narcotic book, and I went home. When I came back the next day at 7am the 11-7 nurse told me that 3-11 nurse missed a bubble of ambien last night. I checked the narcotic book and she signed out a tab. at 9 pm because resident get this med once a day at 9 pm, also she signed in the MAR that she gave the med at 9 pm. The 3-11 supervisor came to me and with an accusatory tone asked me about the medication, because she said that 3-11 nurse told her that she is not sure if she had the medication. what do you do in my case?

not quite sure if you are a dayshift rn why you would be drawn into a discussion about a second shift medication...especially if its not your name on the narc sheet...???am i missing something??

Nurse_Tricia, LPN · May 10, 2010

So this brings up a question I have been wanting to ask because i am so new at this. When we do our count it scares me sometimes with people I count with, they will say"23" no "24". I always try to look at the book- but the other day I was counting and even though the count was correct the nurse kept looking at the wrong number so it was making me nervous. It seems easy that as you are counting someone could just shout out 1 more than what you have and after they are long gone you now have a problem with count but you signed that the count was correct. I hope I am not confusing anyone. Any have any input on this? has this ever happened to anyone?

CT Pixie, BSN, RN · May 10, 2010

So this brings up a question I have been wanting to ask because i am so new at this. When we do our count it scares me sometimes with people I count with, they will say"23" no "24". I always try to look at the book- but the other day I was counting and even though the count was correct the nurse kept looking at the wrong number so it was making me nervous. It seems easy that as you are counting someone could just shout out 1 more than what you have and after they are long gone you now have a problem with count but you signed that the count was correct. I hope I am not confusing anyone. Any have any input on this? has this ever happened to anyone?

When I do counts, I have the off-going nurse who's giving the numbers put the narc book on top of the med cart where I can see it. That way, I can actually SEE the number written down AND the person and med that it goes with.

Saying the incorrect amout like the example you gave (saying 23, no wait, 22..or 38..oops, thats 37) is common, many times peoples handwriting is a bit illegible or you glance at the bottom of the page and the actual count is at the top of the next column type thing. But having the book where I can see it, I know for fact that the number is XX and the pt is XXX and the med is XXX.

pretty70 · May 10, 2010

If the narc count was correct at the end of your shift and 3-11 signed for it, then there's nothing they can do to you. Any discrepancy is now the responsibility of 3-11 and NOT you, because it had to have happened on her shift.
If the Ambien count was off on your shift, then 3-11 should have caught it when she counted with you. Then the missing Ambien would have been your fault, and it should have been addressed with you before you left and she took over, and not waited two shifts. She also should not have signed for it if she knew it wasn't correct.
But if 3-11 didn't actually count the pills and just said "yeah, it's there," as you and her went through the narc book, then it is 3-11's responsibility because she should have actually counted the medication.
They can't blame you for this one: 3-11 needs to keep better track of her narcs and/or count them properly. Tell the 3-11 supervisor that 3-11 counted with you and the count including the Ambien was correct before you left, and that's all you know about the matter.
However, for your own protection, you should make it a habit to physically count each pill at shift change, regardless of who's the offgoing nurse because errors happen to the best of us. Likewise, be sure to count each and every bubble: in addition to the missing-pill-yet-sealed bubbles, I've also had the two-narcs-in-one bubbles. I once had one card with one empty bubble and one with two pills in it, so the count always worked out to match the bubbles. When finally discovered, we told pharmacy ASAP so it could be corrected.
And also get into the habit of checking the count after you give a dose if possible...not always possible in a busy LTC, I know! But at least you'd be able to catch a discpreancy right away.

Thanks to all of you who answer my question. Just to clarify yes we physically counted each pill and signed that the count was correct. Probably the 3-11 supervisor was joking because she told me that in an informal way in front other staff but I really do not appreciate her sense of humor. I take this matter very serious. thanks again to all of you.

Meriwhen, ASN, BSN, MSN, RN · May 10, 2010

Probably the 3-11 supervisor was joking because she told me that in an informal way in front other staff but I really do not appreciate her sense of humor. I take this matter very serious. thanks again to all of you.

And jokes like that can lead to rumors that can be damaging The 3-11 supervisor should know better.

Good for you for always taking it seriously, because it is a very serious matter.