Narcotic Discrepancy!!

[Gericare25]

Okay so I previously had an account on her but changed my email and cannot remember my login info. I am going to try to give as much info as I can to get an answer without too many details.

I work in a LTC facility. It was found during change of shift count with two RNs that a liquid narcotic in the med dispense was actually just an empty bottle. There are two bottles of same med kept in the same drawer. One was fine other was empty. Everyone that has been in med dispense for certain amount of time was called in for statement and interviews.

I was not in the drawer in question to pull the med. I did however help an RN restock a bottle about a week and a half ago. I confirmed there was one bottle in the drawer and we were adding one. I neglected to actually look at the liquid in the bottle. I know this was a mistake on my part but two nurses check it in from pharmacy and I trusted the RN that restocked it. (Won't ever make the mistake of not looking at contents again!). There is no way to tell if the bottle we put away or the bottle that was in the drawer was the empty one.

The med gets counted every change of shift so it has been counted at least 16 times since we put in drawer. I am now freaking out because I can't say for sure the liquid was in the bottle at the time we restocked and I'm afraid they will come back on me for not checking. I still fully trust the RN and know she did not tamper with the med.

I'm not looking for any legal advice but wondering if anyone's been in the situation or known anyone with a similar situation. I'm freaking out as I'm very pregnant and can't afford to lose my job! We've all offered to be drug tested but I know that can't account for people stealing for other reasons. I don't understand how someone could even take the liquid out as it takes two to open the drawer and anyone can enter the room at any time! Any feedback would be appreciated!!

[amoLucia]

You could be talking anywhere from 32 to 64 doses of med unaccounted for!. No - I take back what I said about forgetting to sign for a dose!

To be honest, I think I'm unfamiliar/confused with the type of withdrawal & exchange systems you use. Or it's your system of WHO does what & how & when, etc.

And I hate to say this, but with so much mish-mash counting going on (and not counting and not looking), it would be the perfect opp'ty for someone to deviously pull off a diversion.

Regardless, like you, I think there's going to be some big changes coming in how you conduct your 'counts'. And I also think that EVERYBODY who had access to being in that drawer may be in store for some disciplinary action. How severe???

And just to tell you, Pharmacy will RARELY ever, EVER admit to such a mistake, esp concerning narcs. I truly doubt it. But they could.

Just too many variables in this mix-up. Incl the time lag involved.

(You've been using the word 'consign'; do you mean 'CO-sign'?)

I hope everything works out for you and everyone else.

[Gericare25]

You could be talking anywhere from 32 to 64 doses of med unaccounted for!. No - I take back what I said about forgetting to sign for a dose!

To be honest, I think I'm unfamiliar/confused with the type of withdrawal & exchange systems you use. Or it's your system of WHO does what & how & when, etc.

And I hate to say this, but with so much mish-mash counting going on (and not counting and not looking), it would be the perfect opp'ty for someone to deviously pull off a diversion.

Regardless, like you, I think there's going to be some big changes coming in how you conduct your 'counts'. And I also think that EVERYBODY who had access to being in that drawer may be in store for some disciplinary action. How severe???

And just to tell you, Pharmacy will RARELY ever, EVER admit to such a mistake, esp concerning narcs. I truly doubt it. But they could.

Just too many variables in this mix-up. Incl the time lag involved.

(You've been using the word 'consign'; do you mean 'CO-sign'?)

I hope everything works out for you and everyone else.

Yes I meant co-sign. Not sure why my phone continues to autocorrect to consign! So we have a med cart with a narc box on each hall. The med dispense is only used to pull meds that have not arrived from pharmacy or for "now" meds that are new orders. If a narc must be pulled from the med dispense then we get the dr to call the pharmacy and the pharmacist gives us an authorization code to pull the med. Once we pull the med it is never put back in the med dispense. It is labeled and locked in the narc box on the med cart of the resident it was pulled for.

The narcs in the med dispense are counted by the two supervisors every change of shift. For an example: on the day in question.. dayshift pulled the morphine bottle for a resident down the hall I work. When my shift came in the two supervisors counted and there was only one bottle in the drawer since one had been pulled in the am. (The other was on my med cart and counted by me and day shift nurse on hall). Pharmacy makes their run in the evening and brought a bottle of morphine to restock. The nurse checked it in from pharmacy. She came in the med room where I and another nurse were. She said to me "hey can you help me restock this narc". I said "sure". She logs in and hits restock then clicks the morphine. I sign as witness and drawer opens. It says how many in drawer before adding? I push 1 and then it says "how many are you adding?" I entered 1. She put the bottle in drawer and shuts it. Because the count matches the med dispense totals there are no alerts to a discrepancy.

So for the bottle to have been messed with, it would have to happen at change of shift or when someone entered the specific drawer. Each instance requires a witness unless someone has figured out someone's username and password which I would hope is not the case. I feel we will all be written up since most of us neglected to look at contents of bottle. This is a first for us so we have all become a little lax when we shouldn't have! I feel the write up will be justified. I'm just worried they will try to make an example out of me and the other nurse for not properly restocking the med by not seeing contents in case it was a pharmacy error.

So far they've been calling me everyday to help with orders and admissions so hoping that is a good sign!

[Gericare25]

Just want to thank everyone for their replies! I will update as soon as I know the outcome of the investigation.

[amoLucia]

I have a problem with the fact that 2 RN supers do a count, day in and day out. After they count, they just hand you the keys??

NO way!!! My cart + my keys = my count. I've never known it to be any other way since I started nsg back in the Dinosaur Days.

I think I understand your system better. Any chance there's a camera in your med room?

As I recall at my last place, the Pyxis had some kind of internal memory (?) that could tell you whoever might have opened it and when. That memory can be matched back to individual med administration. Slow, tedious and cumbersome, but doable. There are all kinds of programs and internal applications possible.

For the future, if someone has to make an 'official' correction, make sure you see the correction being entered and explained to you. Even if you don't fully understand how what's being done, the fact that you're monitoring someone else's action makes them more careful. Make them go slow enough so you see there's no phoney baloney going on.

And it's not impossible for someone to get passwords & codes. Nothing is impossible ...

Again, good luck. And let us know what happens. Even if one other nurse comes away from reading this thread with a better appreciation of the seriousness of accurate narc counts, then it's a good learning tool.

[Gericare25]

I have a problem with the fact that 2 RN supers do a count, day in and day out. After they count, they just hand you the keys??

NO way!!! My cart + my keys = my count. I've never known it to be any other way since I started nsg back in the Dinosaur Days.

I think I understand your system better. Any chance there's a camera in your med room?

As I recall at my last place, the Pyxis had some kind of internal memory (?) that could tell you whoever might have opened it and when. That memory can be matched back to individual med administration. Slow, tedious and cumbersome, but doable. There are all kinds of programs and internal applications possible.

For the future, if someone has to make an 'official' correction, make sure you see the correction being entered and explained to you. Even if you don't fully understand how what's being done, the fact that you're monitoring someone else's action makes them more careful. Make them go slow enough so you see there's no phoney baloney going on.

And it's not impossible for someone to get passwords & codes. Nothing is impossible ...

Again, good luck. And let us know what happens. Even if one other nurse comes away from reading this thread with a better appreciation of the seriousness of accurate narc counts, then it's a good learning tool.

Sorry if I'm not explaining this well! There are a set of keys for the supervisors. They count between themselves and the supervisor keeps the keys to themselves all shift. Then we have four hallways and each has a med cart with a narc box on it. Each nurse down the hallway is responsible for their own keys for the med cart. We aren't involved in the med dispense at all unless it is restocking because there is only one supervisor on at a time or pulling a med for ourselves.

I am am not sure if there are cameras in the med room but I'm definitely going to suggest it to hopefully keep this from happening in the future! They are pulling the full report to see who has been in and out of the morphine drawer and when. Hopefully this will give them a better idea of what happened. We are all refining our practice after this scare! I will update when we know the outcome. Thanks again for the replies! :)

[Libby1987]

You put it in the drawer 16 counts ago and haven't counted it since until this last shift and it was discovered empty with another nurse? In the meantime supervisors have been counting it every shift in between, essentially saying the bottle was full?

Other than admitting you didn't confirm the bottle was full (or half full) at restocking, how could you be accused of taking it?

[Gericare25]

You put it in the drawer 16 counts ago and haven't counted it since until this last shift and it was discovered empty with another nurse? In the meantime supervisors have been counting it every shift in between, essentially saying the bottle was full?

Other than admitting you didn't confirm the bottle was full (or half full) at restocking, how could you be accused of taking it?

Thank you for your reply! Your first paragraph is a good synopsis of what happened. I'm not afraid they thought I took it or will accuse me of that. I'm afraid that I will take the fall and be made an example of for not ensuring upon restocking the drawer that the med was indeed full. A long time nurse states that they have done this in the past when they couldn't pin a problem on a specific person. (I've been there 5 years and her much longer).

Honestly as time goes on, I am less worried that this is the case and believe that we will all be held accountable for our part in the issue. Mine is not verifying contents of bottle upon restock and the supervisors are at fault for not checking the contents of the bottle at every change of shift during count. I am willing to take the write up and believe it will be deserved. I will not make the same mistake!

[Tenebrae, BSN, RN]

15mL should have been in the bottle. They come half full from pharmacy for the med dispense. They take a full bottle and split it into two.

whats the rationale behind splitting the bottle into two?

To me thats really dodgy, and puts everyone involved at very high risk of ending up with a narc discrepancy

Not trying to have a go, just curious

[CoffeeRTC, BSN, RN]

whats the rationale behind splitting the bottle into two?

To me thats really dodgy, and puts everyone involved at very high risk of ending up with a narc discrepancy

Not trying to have a go, just curious

I see the reasoning. Morphine SL at .25-1ml will go a long way. I'm guessing they have two bottles of it on hand so it is there in case two different people need an after hours dose.

I have one more question....is the bottle in a box? Our Roxinal comes in a 30 ml bottle with a dropper. It is normally in a box. If it isn't opened and sealed from the manufacturer, I never open it. I would give it a shake.

I work in a smaller facility so our emergency narcs some in a metal box that has tag locks with numbers on it. It is locked in our med room in a drawer. We do not count it unless we open it for a med. Green tag means it is unopened. When it is opened, we verify the number with the sheet inside. Count the meds against the sheet. After we sign out the meds, a red tag goes on it and the box is locked back up. The only time it is recounted is when we go back in to take out another med.

I would think that the RN supervisors that have been counting your meds each shift would be the ones they would look at.

[Gericare25]

whats the rationale behind splitting the bottle into two?

To me thats really dodgy, and puts everyone involved at very high risk of ending up with a narc discrepancy

Not trying to have a go, just curious

It is the pharmacy that delivers the med that way. I don't know for sure why they divide it up. I think maybe they split it because we are only to use the med dispense bottle until a full bottle comes from the pharmacy. So say I pull for patient A because it is a new order from on call dr. They get auth code from dr and we pull from med dispense. We lock in narc box on our med cart and use that. Once our in house dr fills out physical paper script and pharmacy receives it, pharmacy will send a bottle for patient A under their name. We are then supposed to use two nurses and waste the bottle that we pulled from med dispense and begin using the bottle sent directly from the pharmacy. I can only think this is because they make more money this way!

[Ruby Vee, BSN]

Anyone is capable of diversion. It doesn't have to be the nurse that looks strung out and is giving off all the signs of possible substance abuse, or the nurse who everyone knows has the criminal record or the past history of drug use. It could be little Ms/Mr Perfect Nurse. It could be New Grad Nurse or Crusty Old Bat Nurse. And given the rate of substance abuse problems developing among healthcare professionals, it could one day even be You (any of you).

Do not fall into the trap of blindly trusting anyone. If you are there to witness, insist on verifying the contents and amounts yourself. If the other nurse is truly innocent, they won't be offended.

And if failing to properly verify for yourself comes back to haunt you, don't rely on a negative drug test to automatically save your hide, i.e., "the drug test will set me free!" Employers know that not everyone who diverts immediately runs into the bathroom to guzzle it down or shoot it up. They may use it later, or they may never use a drop but sell/give it to someone else. So CYA with properly verifying.

Now that I've scared you witless, going back to the problem at hand...

As it's been quite some time since you last witnessed it and the discrepancy being noticed, I agree with the PP--you're probably fine. A lot has gone on since then and more keeps going on as time progresses--it would make it more difficult to fully pin it on any one person. Who's to say that there weren't other restockings and verifications that you weren't involved in? I think you're OK

That being said, if they pursue the matter further, consider seeking legal counsel, especially if you are innocent.

And from here on out, don't be lackadaisical with narcotic counts and verifications again. As you said yourself, you knew it was a mistake on your part.

Best of luck.

I agree with all of this. Let me just add that you're now on the radar. You're probably OK for this particular incident as so many others have been into the drawer since you were. But if something comes up in the future and you are even peripherally involved, you will be looked at twice. So be extra careful from now on -- do not trust anyone. If you're witnessing, make sure you actually verify.

[Gericare25]

I see the reasoning. Morphine SL at .25-1ml will go a long way. I'm guessing they have two bottles of it on hand so it is there in case two different people need an after hours dose.

I have one more question....is the bottle in a box? Our Roxinal comes in a 30 ml bottle with a dropper. It is normally in a box. If it isn't opened and sealed from the manufacturer, I never open it. I would give it a shake.

I work in a smaller facility so our emergency narcs some in a metal box that has tag locks with numbers on it. It is locked in our med room in a drawer. We do not count it unless we open it for a med. Green tag means it is unopened. When it is opened, we verify the number with the sheet inside. Count the meds against the sheet. After we sign out the meds, a red tag goes on it and the box is locked back up. The only time it is recounted is when we go back in to take out another med.

I would think that the RN supervisors that have been counting your meds each shift would be the ones they would look at.

The bottle comes in a box from pharmacy but we have to open the box and remove the bottle to check it in when pharmacy brings it. The boxes do not fit in the drawer so the bottles themselves are placed in the drawer in med dispense. Our narcs as well as other meds we need after hours are in a med dispense where you log in. Click resident then the med you need. A drawer pops out and you remove what you need then push the drawer back in.