Narcotics ..so I got put on unpaid administrative leave today

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Today is May 10. On April 8, while working a night shift, I signed for a delivery of narcotics and put them in the pyxis, like I do all the time. Except this time. There should have been 4 vicodin in the little ziploc bag. I found 3 and put them in, didn't check the number in the bag against the invoice.

Today I get a call. From my Unit Manager; she's worried about where is the fourth vicodin?? Can I remember? Well, no..of course I can't. Just do whatever needs to be done.

Come in to work tonite, ushered into the office. I am on unpaid administrative leave pending the outcome of their investigation.

Has anyone experienced this? I don't know what I should do...

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Specializes in Critical Care.

When you sign for delivery of narcotics you are signing that the numbers match what's being delivered, I guess I'm not sure what you were expecting would happen.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I am so sorry.....narcs are a big deal. Mistakes are not allowed. Do you remember what happened or do you remember there only being 3 not 4. We cannot offer legal advice ......but if you have call them and talk to them tell them what happened....as them for advice. Every nurse needds to carry their own . Talk to no one and I would not discuss details on social media.

This can turn into a big deal....what I am confused about....did no one give any Vicodin since April 8th? If there was even one Vicodin given .....was the count off then as well? and if not why do they assume it was when you signed them in.

I wish you the best.

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The count was fine. The mistake was found when the company that supplies our drugs conducted an audit. Their invoices showed that we should have ( for example) received 4 vicodin that day. When the pyxis was counted by them a month later,they discovered that I had only put 3 vicodin in the pyxis that day. I honestly can't remember anything odd happening...if there were 3 in the bag, I put 3 in the machine. At my facility, totes with meds, including narcotics, are left sitting on the counter,open. If you sign for a tote, you are supposed to put it away...but that doesn't happen. I have put away meds ( including narcotics) that have been sitting open for hours, sometimes more than 24 hrs. At any time, meds could be removed and unaccounted for. Yes, it is my fault for not triple checking the invoice vs the count printed on the bag vs the number of meds actually present.

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Specializes in Emergency.
The count was fine. The mistake was found when the company that supplies our drugs conducted an audit. Their invoices showed that we should have ( for example) received 4 vicodin that day. When the pyxis was counted by them a month laterthey discovered that I had only put 3 vicodin in the pyxis that day. I honestly can't remember anything odd happening...if there were 3 in the bag, I put 3 in the machine. At my facility, totes with meds, including narcotics, are left sitting on the counter,open. If you sign for a tote, you are supposed to put it away...but that doesn't happen. I have put away meds ( including narcotics) that have been sitting open for hours, sometimes more than 24 hrs. At any time, meds could be removed and unaccounted for. Yes, it is my fault for not triple checking the invoice vs the count printed on the bag vs the number of meds actually present.[/quote']

This sounds like a risky process for the staff, and it definitely sounds like it would promote inventory shrink. For example, at my workplace, a pharmacy tech comes up to the unit with the narcotic drop. She then modifies the count sheet to reflect the new totals eg 10 Vicodin plus 4 Vicodin, now there is 14 Vicodin. Then she grabs a nurse who is available who opens the cupboard and together we count the existing stock and the new stock ensuring the count is correct. Only after this is completed does the RN sign off on the narcotic count and the delivery sheet. Every place I have ever worked has had a similar procedure, it covers everyone's bums.

I'm sorry this happened to you. Perhaps once you get your legal troubles settled this could be the impetus for a policy change, sounds like it is needed.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
The count was fine. The mistake was found when the company that supplies our drugs conducted an audit. Their invoices showed that we should have ( for example) received 4 vicodin that day. When the pyxis was counted by them a month later,they discovered that I had only put 3 vicodin in the pyxis that day. I honestly can't remember anything odd happening...if there were 3 in the bag, I put 3 in the machine. At my facility, totes with meds, including narcotics, are left sitting on the counter,open. If you sign for a tote, you are supposed to put it away...but that doesn't happen. I have put away meds ( including narcotics) that have been sitting open for hours, sometimes more than 24 hrs. At any time, meds could be removed and unaccounted for. Yes, it is my fault for not triple checking the invoice vs the count printed on the bag vs the number of meds actually present.

Then this needs to be remembered as brought to the attention of administrators

At my facility, totes with meds, including narcotics, are left sitting on the counter,open. If you sign for a tote, you are supposed to put it away...but that doesn't happen.
and call a supervisor for this......
I have put away meds ( including narcotics) that have been sitting open for hours, sometimes more than 24 hrs. At any time, meds could be removed and unaccounted for.

I have seen many good nurses take the fall for facilitates bad practices for when they make up a "correction action" to rectify a problem...firing a nurse is very often part of the "corrective action taken".

Just because "everyone does is or does it that way" will not help you in the long run.....like I said I completely believe you your innocence and this was found during an audit.....If you have call them as ask for advice.

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The count was fine. The mistake was found when the company that supplies our drugs conducted an audit. Their invoices showed that we should have ( for example) received 4 vicodin that day. When the pyxis was counted by them a month later,they discovered that I had only put 3 vicodin in the pyxis that day. I honestly can't remember anything odd happening...if there were 3 in the bag, I put 3 in the machine. At my facility, totes with meds, including narcotics, are left sitting on the counter,open. If you sign for a tote, you are supposed to put it away...but that doesn't happen. I have put away meds ( including narcotics) that have been sitting open for hours, sometimes more than 24 hrs. At any time, meds could be removed and unaccounted for. Yes, it is my fault for not triple checking the invoice vs the count printed on the bag vs the number of meds actually present.

As another poster said...when it comes to narcs, it needs to be made a priority. Even if someone is coding, you tell the person that nobody can sign until the code is over. When someone signs for the narcs, they need to go into the machine immediately.

Your facility has not made this a priority, therefore, have not made this a priority for the staff, but obviously, they made it a priority when it comes to accounting for the shortfall.

I would REQUEST to take a drug test immediately, offer to do an in-service of what should happen and offer to supervise the fact that they should go directly into a drawer. New disciplinary action needs to be taken on nurses that don't put narcs in the machine and sign for them and leave them out.

That protects everyone involved. Because you could also have a delivery person that is taking the narcs...that is the second reason why they need to be counted.

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Specializes in Psych ICU, addictions.
Just because "everyone does is or does it that way" will not help you in the long run.....like I said I completely believe you your innocence and this was found during an audit.....If you have malpractice insurance call them as ask for advice.

"Everyone does it this way" only works until something goes wrong, like it did here. Then you'd be surprised how self-righteous "everyone" can get :/

And unfortunately, only the one involved when something goes wrong (in this case, you) is usually the only one in trouble, because you were the only one "caught."

You could (should) offer to be drug tested, but don't expect the negative results alone to resolve the whole matter. You'd be surprised how many people divert not for their own use, but to supply others and/or sell. And facilities know this.

I agree with Esme: call your , explain what happened and get their advice. If you don't have insurance, it may be worth springing for a lawyer--in the long run, that's cheaper than having to find work with a license that has disciplinary action on it, or having to deal with your last employer tell future ones that you were sacked for mishandling narcotics. Handling narcotics really is no joke.

Best of luck.

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Specializes in Pedi.
This sounds like a risky process for the staff, and it definitely sounds like it would promote inventory shrink. For example, at my workplace, a pharmacy tech comes up to the unit with the narcotic drop. She then modifies the count sheet to reflect the new totals eg 10 Vicodin plus 4 Vicodin, now there is 14 Vicodin. Then she grabs a nurse who is available who opens the cupboard and together we count the existing stock and the new stock ensuring the count is correct. Only after this is completed does the RN sign off on the narcotic count and the delivery sheet. Every place I have ever worked has had a similar procedure, it covers everyone's bums.

I'm sorry this happened to you. Perhaps once you get your legal troubles settled this could be the impetus for a policy change, sounds like it is needed.

That's how it worked when I worked in the hospital too... pharmacy tech came to the floor to refill the pyxis with a printed invoice of what they were bringing. Two people had to be present to refill the pyxis so tech grabbed a nurse who wasn't busy. If I was that nurse, I would go with the tech to the med room and he/she would hand me the invoice. Tech would then select medications to refill, if we were refilling morphine 2mg/1 mL syringes, pyxis would prompt us to count what was already there and then ask for how many we were adding. Tech brought ten and I would verify that indeed ten were placed in the pyxis before signing my name. When a nurse logged into the pyxis "refill" was not an option, only pharmacy had access to refill the pyxis and that was their responsibility.

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Well, the corrective action was a one day suspension without pay. When i returned to work, my supervisor told me that if a narcotic delivery arrives and I didn't have time to put it away immediately, I should lock it in my cart until it could be put in the proper place. It's going to be a VERY LONG TIME before I sign for any narcotics again. I am hoping that this doesn't adversely affect my license. I did not offer a urine test or tox screen; the meds came up missing over a month ago. Not that I think it would matter one way or the other. I learned a valuable lesson.....double and triple check from now on. Thanks to everyone for the helpful comments and input...

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Just a reminder to everyone to CYA no matter what. I'm glad nothing more came of this.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Lessons learned....((HUGS))

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