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!!

[Gericare25]

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.

Believe me, I have learned my lesson! I will be even more careful with being a co-signer and with the narcotics in general. I think I can be a little naive and trusting but this has scared me enough to make sure I'm asking the other nurse to slow down for my own comfort. I don't want to have to deal with any situation like this ever again!

[Gericare25]

Thanks everyone for all of your replies! So they still haven't been able to figure out what happened but some nurses admitted to signing into the med dispense as a witness for other nurses and then leaving the room which is obviously a very big no no! They have revamped our whole change of shift narcotic count and will be rolling it out next week. We all received education on being a proper witness and the supervisors always check the contents of the narcotics during their counts now. We got two tags from the state for the issue. We asked about a camera for the med room but they don't know if it'll fit in their budget. I think the tags from state might push them that way! Again, thanks for everyone's thoughts while I was stressing. I have def. learned my lesson and hoped the other nurses have as well.

[RNOTODAY, BSN, RN]

Thank you for your reply! I will definitely always be checking the actual liquid in the bottle no matter who the other nurse is! I have learned my lesson and it was my lesson to learn because it's just good practice. I will be obtaining legal counsel if it gets to that point. There were at least 16 counts (we work 12 hour shifts but sometimes the supervisors split shifts so there could have been more) in between when I consigned the restock and when they found the empty bottle. That was the only time I was in that drawer but they are waiting for the full report from pharmacy to see who all the change of shift counters were.

I was honest in my statement and told them that I did consign to restock a bottle on the date I worked and that I failed to observe the actual liquid in the bottle we were adding and the bottle that was already in the drawer. I saw a bottle in the drawer and saw the nurse add 1. May not have been the smartest thing but I couldn't in good conscience say I saw the liquid when it may have been empty at that time. :/ I know many of the supervisors including the acting DON (is actual ADON) also stated that when doing counts they count bottles and fail to look at the liquid. This practice will obviously be changing!

You can't tell if you are holding an empty bottle opposed to one with liquid in it?

[dream'n, BSN, RN]

Thanks everyone for all of your replies! So they still haven't been able to figure out what happened but some nurses admitted to signing into the med dispense as a witness for other nurses and then leaving the room which is obviously a very big no no! They have revamped our whole change of shift narcotic count and will be rolling it out next week. We all received education on being a proper witness and the supervisors always check the contents of the narcotics during their counts now. We got two tags from the state for the issue. We asked about a camera for the med room but they don't know if it'll fit in their budget. I think the tags from state might push them that way! Again, thanks for everyone's thoughts while I was stressing. I have def. learned my lesson and hoped the other nurses have as well.

OK this answered my question. I was wondering how a dispenser that takes 2 RNs to open and verify could be diverted from (but I understand now that some witnesses where leaving other nurse's ALONE in the area with the open dispenser). A-HA, that explains how someone was able to divert.

[LovingLife123]

Too many hands touching one narcotic bottle, the whole way from pharmacy on down. This was bound to happen. That whole policy needs to be overhauled.

[Nurse SMS, MSN, RN]

I am glad this is working out for you. You don't have to be suspicious of all your co-workers, just prudent with your own accountability and license. Never think it can't happen to people you trust. There is this assumption in the US that drug addicts are all dissolutes that can be easily spotted and targeted, which makes the actual perpetrators harder to spot and the shock of the situation more difficult to get your head around, since most of the time it is actually a person you would not have expected. An individual I went to nursing school with got caught diverting on the job within the last year. If I had to draw up a list of people I have schooled and worked with who I thought would potentially get sucked into addiction with diversion activities, this individual would not have even been on my radar. Very kind, soft spoken, quietly religious, great parent and all around wonderful person.....not at all the "profile" we imagine in our heads of who is a potential addict and criminal. They are in recovery and doing great and I am glad, but I never would have suspected them in a hundred years and likely would have rationalized any niggling suspicions away due to my unshakable opinion of who they were being absolutely at odds with the idea of a narc diverter. They are still all those things..but now dealing with an illness called addiction. Thank goodness they were caught and able to make recovery without killing any patients or themself.

[TheCommuter, BSN, RN]

There is this assumption in the US that drug addicts are all dissolutes that can be easily spotted and targeted, which makes the actual perpetrators harder to spot and the shock of the situation more difficult to get your head around, since most of the time it is actually a person you would not have expected.

You hit the nail on the head. Most of the addicts with whom I have been acquainted are middle-class educated professionals. They have homes, families, and nice jobs. Most of them had gregarious personalities and did not look or act like stereotypical street people.

[amoLucia]

... There is this assumption in the US that drug addicts are all dissolutes that can be easily spotted and targeted, which makes the actual perpetrators harder to spot and the shock of the situation more difficult to get your head around, since most of the time it is actually a person you would not have expected.

It is sad that other dysfunctional characters such as alcoholics, child molesters, spousal abusers, granny abusers, etc can be substituted into this quote. Sad reality.

Back to the original post.

[Gericare25]

I never personally held the bottle of Morphine. The RN supervisor had me witness she was adding the bottle to the med dispense. I did witness her put the bottle in but made the mistake of not looking at the contents of the bottle. When the supervisors were counting the narcs in the med dispense at change of shift they were looking in the drawer and seeing two bottles but not picking them up and verifying contents. This has been changed as well!

[Gericare25]

Our pharmacy has overhauled their Morphine protocol. They have changed suppliers and will no longer need to open the bottle and add the dye. (It came clear to them and they would add red/pink to it). They also won't be splitting the contents of one bottle into two. Now the bottle will come with an inside seal and the liquid is blue. So now we open the lid and verify it is sealed and also check the contents!

Not sure the outcome of the investigation but the one nurse (not the supervisor I restocked with) resigned without notice and it was a resign or be fired situation. She had multiple narc errors this year so far.

[amoLucia]

Uh - oh! Am reading this late but again all I can repeat is Uh - oh!

I would hope that I'm wrong, but sounds like that 'resigned' nurse may have had a problem that is all too present in healthcare professionals with easy access to narcotics.

It's been said in this post that drug abuse can affect anybody and it's not like all drug abusers wear a big red 'D A' on their foreheads (like Hester's Scarlet Letter A). Abusers are very adept at hiding their needs and they also can so very easily identify 'the weakest links' when they need to meet their needs.

I'm glad the facility revamped its narc protocol. And that OP learned a crucial lesson re narc counts.

To OP - TY for the comeback re the investigation.