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
Specializes in med/surg, telemetry, IV therapy, mgmt.
Many years ago one of the RNs who worked on our hospital unit was arrested for stealing narcotics. We were all shocked and couldn't figure out what she had been doing because it had apparently been going on for more than 6 months or more. This is what she did. . .(remember, this was in the days before Pixus)when the pharmacy sent up 20 doses of Demerol she would remove both the Demerol and the signoff sheet and pocket them. One of the reasons it had taken them so long to figure out what was going on was because she worked on a surgery floor where narcotics were given out to almost every patient. So, sending up new supplies of narcotics was not out of the ordinary. Shortly after her arrest we had to start accounting for every signoff sheet that went into and out of our narcotic notebook as well as the narcotics themselves.
As an old accounting clerk before becoming a nurse I can suggest that when you cannot find the reason for a counting discrepancy, the accountants start working each step they had taken to arrive at their wrong answer backward to find the error. No lie, our bookkeeeper hunted for 2 days for 3 cents. Her debits and credits of the general fund were off by 3 cents. She went nuts looking for it. She had all of us take a crack at re-adding the figures. Finally, one of the auditors walked in and in about 5 minutes he found the error. He just calmly asked if she had gone back and checked all the individual accounts to see if they balanced. No, she hadn't. It was the next to last step before the 3 cent error had shown up. Sometimes a pair of fresh eyes with a little experience can see things from a different point of view.
After working 3 years in an ER with a pyxis all we did was count incoming narcs and sign then done, I moved to SICU which we count every shift primarly post op hearts we give more morphine that water not to mention sedating vent pt with ativan. I have to think the amount of time spent on the clock by 2 shifts twice a day to count even on the days with no disp cannot be more cost effective than a pyxis.
Daytonite, BSN, RN
1 Article; 14,604 Posts
Many years ago one of the RNs who worked on our hospital unit was arrested for stealing narcotics. We were all shocked and couldn't figure out what she had been doing because it had apparently been going on for more than 6 months or more. This is what she did. . .(remember, this was in the days before Pixus)when the pharmacy sent up 20 doses of Demerol she would remove both the Demerol and the signoff sheet and pocket them. One of the reasons it had taken them so long to figure out what was going on was because she worked on a surgery floor where narcotics were given out to almost every patient. So, sending up new supplies of narcotics was not out of the ordinary. Shortly after her arrest we had to start accounting for every signoff sheet that went into and out of our narcotic notebook as well as the narcotics themselves.
As an old accounting clerk before becoming a nurse I can suggest that when you cannot find the reason for a counting discrepancy, the accountants start working each step they had taken to arrive at their wrong answer backward to find the error. No lie, our bookkeeeper hunted for 2 days for 3 cents. Her debits and credits of the general fund were off by 3 cents. She went nuts looking for it. She had all of us take a crack at re-adding the figures. Finally, one of the auditors walked in and in about 5 minutes he found the error. He just calmly asked if she had gone back and checked all the individual accounts to see if they balanced. No, she hadn't. It was the next to last step before the 3 cent error had shown up. Sometimes a pair of fresh eyes with a little experience can see things from a different point of view.
Glad you found your "missing" narcotics.