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Discussion

Narcotic count (why it is off, how to fix it, how do you do it?)

It is never right! I told the higher ups we need an in service (and to crack a few heads over the carelessness) and the higher ups tell me to get the info together and they will present it.

At our facility we are still counting manually and using the ledger method. To add/remove a card of drugs a nurse is to do the following.

To add a drug to locked box - Pharmacy delivers a drug, nurse signs for it. Nurse (ideally 2 nurses) records drug on "narcotic accountability inventory check" (NAIC), places "proof of use sheet" in ledger and puts drug in locked box.

To take a drug (the whole card not one dose) out of the locked box -remove card from box, pink out entry on NAIC and have 2 nurses initial. If there is drug remaining sign (2 nurses) it into pharmacy narc box. If all of the drug has been consumed turn "proof of use sheet" into charge nurse.

For the q shift narc count the oncoming nurse counts narcs and the off going nurse has the ledger. After the count of the individual doses is done the oncoming nurse is to count the cards (our narcs come in the bubble packs) in the box and the off going nurse is to count the entries in the NAIC that are not pinked out. The number of cards should match the number of NAIC entries.

The problems are happening with the NAIC sheets. The first and easiest problem to fix is people are not pinking out the corresponding entry when a drug is DC'd (removed from locked box because all of the drug was used, there was an order change etc).

Second problem, pharmacy delivers 4 cards of 30 (120 total) for a patient. Some nurses make 4 individual entries on the NAIC others will "bundle" the 4 cards into 1 entry. So you never know if you should count each card or each bundle of cards because no two nurses enter the drugs the same way onto the NAIC.

I spent 2 hours auditing the box today because I found a descrepency. I had to go through card by card comparing them to the NAIC. This is not an easy task because the only order to the NAIC is that drugs are entered by the date they were delivered. Some nurses when wielding the big pink marker don't look at the date and just match name,drug,dose so most of the time the dates are not really helpful. By the time I made it through the box I found 3 items that were removed but never pinked out (Charge nurse had the completed "proof of use sheets" thank God. I also found one entry that had been bundled ( 2 cards of 3o entered into the NAIC as 1 card of 60).

For anyone who could make sense of all of that (I tried my best) do you have any suggestions? How dose your facility handle narcs? Any and all ideas welcome.

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    • Featured Replies

    Yikes.... just reading this I got lost :) It sounds overly complicated. And discrepancies that are routine are federal issues- you do not want the feds in the building from what I hear- it's beyond a nightmare.

    The blister cards are pretty routine in LTC- and such an easy way to count narcs. It shouldn't be a problem, unless someone has a "problem"... the oncoming nurse counting the actual cards (and verifying the right number of pills in the bubbles) is correct- the off going nurse follows along on the sign out sheets. That should be the end of the story w/counting.

    When giving narcs, take card- press med out- sign sheet, and lock card back in the locked drawer. The end.... (well, be sure resident gets med- that would help). :)

    All of the pinking in and out could be an issue- is duplicate "pinking" happening, making it look like there are fewer meds left? Why do the pink thing (using a pink highlighter???) - if you sign on the right numbered line, it's still easy to see...and another step that can't get messed up.

    And you have got to get everyone doing the same thing- without exception- if some don't like the agreed upon method, well tough boogers for them.... it's not about convenience- it's about being legal.

    IMHO, y'all need to make it simple. The more steps you have to complete one task the greater the chance for ongoing problems ...

    Good luck :)

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    • Guides

    "Proof-of-use" sheets.......are you saying that you're using a loose-leaf binder? That's just asking for trouble---it's way too easy to make both a ledger sheet and a card full of narcs go away. Your pharmacy should be supplying you with bound narcotics books with numbered pages, which (of course) should correspond with the numbers you hand-write on the cards in permanent marker as you receive them. Narcotics counts should always be done without distractions---no chatting about other things, no residents or CNAs in the med room etc. while count is taking place---and expired or D/C'd C-2's should be destroyed as soon as possible, preferably by the DNS and another manager. (At my facility, the care coordinator and I destroy narcs twice monthly and PRN overcrowded drawers.)

    But whatever you do, CONSISTENCY is the key, and the expectation for everyone who gets into those med carts is to do things in the same way. I've seen facilities barbecued by state surveyors for inconsistent narcotic documentation, and believe me, nobody wants to see the feds in their building. :nono:

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    We had loose leaf notebooks, but the pharmacy provided the sheets w/patient name, and basic rx info on a sticker placed on the sheet (you couldn't remove one of those things without destroying the paper under it).

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    Sounds like you have an impaired nurse stealing, you first figure out who this is then the narcotic problem will come out right, DRUG test all the nurses who have access to the narcotics......:rolleyes:

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    Sounds like you have an impaired nurse stealing, you first figure out who this is then the narcotic problem will come out right, DRUG test all the nurses who have access to the narcotics......:rolleyes:

    Where do you get that? The "missing" cards, as I understand the OP, were accounted for by the "proof of use" sheets - assuming that means the sheets on which individual doses were signed out. It's good to maintain a healthy index of suspicion re diversion, but with so much chaos in how inventory is handled I think the OP is right to get control of the process first before throwing around accusations of impairment.

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    • Author
    We had loose leaf notebooks, but the pharmacy provided the sheets w/patient name, and basic rx info on a sticker placed on the sheet (you couldn't remove one of those things without destroying the paper under it).

    That is exactly what we have. You could not remove the sticker without problems but a person could remove the whole sheet from the ledger. I think that is the reason the NAIC was originally put into place.

    This is the only place I have been that has inventory sheets. It is a cumbersome, inconsistently used and troublesome process.

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    • Author

    "The "missing" cards, as I understand the OP, were accounted for by the "proof of use" sheets - assuming that means the sheets on which individual doses were signed out."

    Yes that is right. So far any errors I have found have been related to the NAIC. All of the "missing" cards have been accounted for by the proof of use sheets (the paper you sign out individual doses on). All of the problems up to this point have been due to the NAIC.....Paper work mistakes, not missing drug mistakes.

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    • Experts

    People need to be held accountable for not following policy and procedure. Some nurses don't realize the enormity of having a suprise inspection by the DEA/federal government and health department would cause to them and the facility. Thye also need to be reminded that the improper documentation/including the signing out of narcotics can lead to disciplinary action action up to and including revocation of their license.

    I dealt with lazy documentation once as a manager and after a thorough inservice and making it explicitly clear the consequences of failing to follow policy as well as making personally sure that everyone was clear on how to document.........I began my progressive disciplinary plan. After a few write ups and progesssive consequences........1) write up verbal warning, 2) written warning, not able to work any OT (big at this facility) while on warning and 3) action.....when the first nurse (a tough nut to crack)got 2 days off without pay, they all suddenly became very serious AND compliant.

    Sounds tough but all need to realize the significance and seriousness to proper narcotic documentation and that it is more that getting the numbers right. Unfortunately, electronic dispensing is the best answer. The LTAC I worked for eventually (yeasrs later) got PYXIS machines for the dispensing of narcotics. I remember we had narcotic sign out sheets that were like written checks in ledger format with the automatic copy produced and counted every shift with a strict double signature and on comming off going nurses counting every narc so that issues are addressed immediately. They had a "inventory sheet" of narc count and any issues found that they both signed and gave to me so I could address any issues immediately that was completed every 24 hours. Like balancing your check book every 24 hours........ It was difficult at first but once everyone got the hang of it the problems ceased to exist.....:rolleyes:

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