Published Sep 2, 2005
estrogen
227 Posts
Geeeeez! This am during narc count, we come to the very last page of the Schedule III book. And I say, wait a minute, there's one more page... A brand new full card of 20 Vicodin that I received from pharmacy last evening. "Nope," says the oncoming nurse, "I don't see any Vicodin for pt XYZ" .....She goes through all three schedules "Nope, it's not here..." I start sweating a little, but I'm still thinking Ahhhh, it has to be here somewhere... I go through all three med carts that I was responsible for during NOC schift. I just know I put it in there somewhere. I had the pharmacy sticker and I entered it into the book afterall... I searched the entire med room and all three carts over and over. Not one, but 20 Vicodin!!! In my mind I allready saw my job and my license being flushed down the toilet. I saw myself in court, investigated, interrogated, branded for life, loosing my livelyhood, my familiy, getting divorced and eventually landing on the streets a complete failure....
Eventually I was shaking, nauseaous and I had pretty much the entire house up in arms. I refused to leave untill the DNS comes in, I had the oncoming nurse for the one cart where the med was missing from search my purse, my pockets and I was going to have someone search my car as soon as the DNS comes in, before I ever leave the premises. I was also going to demand a urine test immediately.
After an hour and a half of searching through the carts, under the carts, all around the carts I discretely told the other nurse, that I'm starting to doubt my vigilance and that I have no other option than to start thinking that one of the three chronic narc seeker patients, that circulate my carts on a regular basis every night, one of the CNA's or one of the eve nurses (since I accepted the med from pharmacy right around shift change) might have took it, as I perhaps left it on top of the cart and turned my back to it or something.(I am usually very vigilant and very very careful, but after two hours of searching you start absolutely doubting yourself.) We asked one trusted CNA to inconspicuously search (or at least visually inspect)those residen't rooms. I was absolutely crushed, could not believe that this is happening to little anal miss precision me, yet at the same time I was doubting and blaming myself tremendously and was absolutely convinced that it is my fault and that I will pay dearly.
Management was still nowhere in sight, as the ex-day shift charge nurse, now MDS nurse came walking in. Me and the other nurse went and explained what happened. At this point I was stuttering, searching for words... completely frazzled, probably made the impression of a very unhappy lost little girl, rather than a competent and confident nurse. So the ex-charge nurse, now MDS nurse goes over to the affected cart and proceeds to count the narcs one more time. In about a minute she casually pulles the card out of the cart with a little bit puzzled, a little bit amused look on her face. "Twenty Vicodin fro Mr. XYZ, page 35? Oh they were just misfiled with the Schedule II."
How is that possible????
It took a third set of eyes of someone who just came in and was unaffected by the preceiding two hours of stress and scramble, to see the obvious...
Immediately I started crying, appologizing for the upset and thanking everyone. I went home feeling very relieved and very embarassed at the same time.
After I came home, I realized, that throughout the entire time, I searched all three carts about three or four times - hundreds of punch cards, but not once did I re-count the affected narc drawer. I took the other nurse's erroneous count for granted... two, three, or maybe even four times. She was so supportive and reassuring the whole time, but at the same time so wrapped up in the conviction that the count is wrong, that she somehow miscounted over and over...
Am I not the biggest DORK on the face of this Earth??? :chuckle :imbar
sirI, MSN, APRN, NP
17 Articles; 45,819 Posts
Bless your heart. I know you were livid. I felt sooo badly for you reading this and I KNEW the outcome before you said what the problem was.
You were right on to not leave until all was o.k. In fact, in my facility should a count not be correct, NO one leaves that shift.....
I am glad everything turned out o.k. Relax and pat yourself on the back. :balloons:
casper1
198 Posts
Why do we Nurses have to go into a total panic when a narc is missing? I've also seen my life flash before my eyes when the narcotic count is off. All the things we have to worry about it doesn't seem fair we have to go into a melt down when thew count is off. I've seen staff held over the end of their shift more than an hour waiting for the count to be corrected. I can see worry if they wonder if a patient got the incorrect medication. But I doubt 20 vicodin were given by mistake. It just doen't seem fair to me that nurses have to worry their careers will be destroyed and they might be sent to prison just because a count is off.
babynurselsa, RN
1,129 Posts
I can just imagine how panicked you were at the time. I know I would have been.
Sometime one that panick sets in we cannot see what it right in front of us. Thank goodness all turned out well. Yes, sometimes it takes that calm rational set of eyes to see what is right in front of us.
Just remeber to take a deep breath, then another then another.....
We can forget to do this at times like that.
sparkplug
37 Posts
Wow
I never would have thought of a urine test but I would not have slept when I got home either. I am so glad this turned out ok for you.
I agree. There should be a better way of keeping track of narcotics than putting us nurses under such stress twice in every shift. In this day and age, where there are such high tech means to solve nearly any practical problem (especially one that seems so trivial as this), it shouldn't be so hard to come up with some way of keeping the nurse out of the equasion (ie, a pixys type device). It is not fair putting us nurses under such pressure on such a regular basis.
CoffeeRTC, BSN, RN
3,734 Posts
Do you have separate ways of keeping track of narcs? We have one locked box per cart..all controlled drugs in the same box.
stidget99
342 Posts
I can totally understand the panic that you went through. I panic every time I enter the Pyxis for a narc and the count is wrong and a discrepancy is created. If there is another nurse nearby I have them witness for me but what do you do if you are the only one in the room???
Tweety, BSN, RN
35,420 Posts
All's well that ends well. :)
Yep, so do we. Three carts, three narc boxes, six counts per shift for me.
meownsmile, BSN, RN
2,532 Posts
You arent the only one who has had those dorky days. I signed in 10 vicodin one day from pharmacy, was as usual going straight to the cart to put them in the lock up, and inadvertently let myself get distracted and stuck them in my pocket. Took me almost an hour to realize what i did,, and boy didnt i feel like a ditz. We all have our days,, i guess we should just be glad they rectify themselves and we learn the hard way to be more careful.
NurseCard, ADN
2,850 Posts
All I can say is, thank the LORD for our Omnicell. =) Now we only have to count a few drawers once in 24 hours. It's great.