Forgot to put narcotic back in Pyxis

Nurses Medications

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This Friday I had a situation that occurred regarding narcotics but I'll start from the beginning. I work on a telemetry floor which the nurse to pt ratio is usually 1:6, since it was the day after Thanksgiving the census was about 28 in a 42 bed unit which left me to have 4 pt at this time which is awesome. The day started out good I knew 3/4 patients so report was short. I start going in my usual routine doing my assessment on my patients, then I start charting then after that I take out my medications. One pt in particular was confused and yelling so when I was taking out my meds I took out Xanax for that pt. When I was about to give my meds the PCA asks me to help one of the patients which was the one that was yelling before but this time the pt was calmer. After that I started to give my meds to my first pt then I reached to the confused pt. I decided not to give Xanax because it was unnecessary, the pt was not trying to get out bed nor yelling and the pt had a tabs alarm to.. So I left the Xanax in my locked cart in which I was meaning to return after giving meds and so I moved on to my next pt.As I finished administering all my meds a code blue on my unit occurred which of course all of the nurses ran to the room to help out. Then 5 mins after the pt was sent into the ICU, my confused patient was not responding and the breathing was labored and the only way to check the BP was manually which the systolic was heard in the 50s. I immediately called RRT which then turned into code blue however in the chart the pt had DNR A paper but was not signed. In the end we were able to stand by the DNR because there was an order on the computer for DNR A so we stopped CCPR. This pt was 91 with cancer that has spread and the family member knew the pt was dying. Unfortunately in the end the pt died, this was the first time I experience a death while working. I had to do postmortem care and chart and call the sharing network. I discharged 2 pt leaving me with 1 pt left since my pt expired. I got 2 back to back admissions along with that. Mind you this I forgot all about the Xanax I left in my locked cart. In the end of my shift I usually take all of the meds that weren't given and put it in the pharmacy outbox in which the pharmacy techs pick up. I forgot I had the Xanax in the cart which I put that in outbox. I realized that I forgot to return the Xanax this morning at 4:40 AM and called my RN friend to see if the Xanax was there and she told me pharmacy already cleared the box. Then the night RN told me I was being staff adjusted which meant I didn't have to come to work. I asked my friend who was checking narcotics which luckily was one of my closest nursing buddies and told her my situation and to let me know if there were any discrepancys. She then texted me saying there wasn't any discrepancys, but I'm still worried especially since it's a narcotic. I know for sure that I put all unused meds in the pharmacy outbox but who knows if one of the pharmacy techs saw xanax and took it. I just feel extremely stupid because I didn't check the meds first before putting in the outbox. I just wish I return the narcotic right away or checked the medications I was putting in the outbox. Should I report this first thing in morning tomorrow?

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Specializes in PACU, pre/postoperative, ortho.

Yeah, I think you need to follow up. The pyxis wouldn't show a discrepancy assuming the count was correct when you took out the xanax. However, there is record of you removing a controlled substance (benzo, not a narcotic btw) but not administering it to the pt.

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What do you think of the consequences of taking out the controlled substance and not administering it. I'm really worried about it. Should I discuss this with the charge RN tomorrow and call pharmacy to see if there was a controlled substance found in the outbox on Friday?

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I would find out who found the Xanax and ask them how they disposed of it, it may have been returned to the pharmacy

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Specializes in Med-Surg.

Is "staff adjusted" the same as being cancelled due to census? Or is it being told not to come for disciplinary reasons?

Hopefully the pharmacy tech saw the Xanax and returned it. Worst case scenario in my hospital that would result in an incident report with a mini root cause analysis (where your shift would be discussed, distractions, the patient coding, ect...) and you would sign a warning or a write up. If the Xanax was not found, then you would be asked to take a drug test and it would probably be a more serious investigation.

Still, in the grand scheme of things, I hope they are somewhat lenient about it. You had quite a busy shift.

Unless the other patient needed immediate attention, you should have told the PCT you would be there after returning the med to the Pyxis. Hindsight is 20/20 though, and I know you aren't able to anticipate the rest of the shifts events.

I hope it works out okay for you.

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They asked me to go home because the census was low and it was my turn on the unit for being staff adjusted and thanks for the advice I appreciate it

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Be clear about it. You patient coded, therefore, any meds you pulled would not have been given.

It was in a pharmacy outbox. Therefore, you disposed of the medication (along with what I assume was the rest of the ungiven meds for this patient)

If the patient were alive and agitated and not within the parameters of the administration time for the next nurse (the pyxsis put up big red warning box) and the next nurse was left not knowing what was happening and the patient escalated and needed that med, THEN it would be a huge issue.

Always assess your patient first, pull and give accordingly. Don't go by who says what to who and pull according to hearsay. It I hard to explain to your witness return nurse that you pulled the med and did not assess first. Not great practice.

And if your patient was actively dying from CA, chances are that the PO Xanax would not have been tolerated to begin with. So pulling that was not a great judgment call to begin with. So good idea going forward to perhaps use this as a policy changer.

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She never said she took it out on the PCA's account. She said she took it out before the PCA asked for help with a different patient.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
What do you think of the consequences of taking out the controlled substance and not administering it.
Only the director of pharmacy and perhaps a nurse manager at your workplace could accurately answer this question since these people are more knowledgeable about the policies there.

The withdrawal, return, and wastage of narcotics from the Pyxis machine are all governed by strict federal DEA rules. Typically, any controlled substance that is withdrawn from the Pyxis needs a corresponding record of having been scanned, returned or wasted within a specified time frame.

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Specializes in LTC, Acute care.

I always pull pain meds for everybody in the morning because 9.5 times out of 10, they'll want it. With 5 pts all wanting pain meds first thing in the morning, I don't have the luxury of assessing them first then going to get their meds. The next thing I do right after report is to try to be the first in med room to get meds as I hate standing in line and if I start late, it puts me behind all shift. I assess after it's pulled, and when I'm in their room, then give as long as their vitals are stable. If for some reason, it's that 0.5 pt that declines a pain med, I have no trouble finding a witness to return it to the Pyxis. It's usually unopened anyway. Where I work, we're encouraged to always have pain meds in hand before going to see a pt as opposed to seeing them, them asking for it and you having to run to med room to get it. Nobody has ever given me grief for being a witness nor have I ever given anyone else. I just make sure what I'm being shown corresponds with the Pyxis screen.

I'm sorta responding to your second to last paragraph...

(reply to Jade's post, *shucks I should have quoted it*)

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Specializes in Med-Surg.
I always pull pain meds for everybody in the morning because 9.5 times out of 10, they'll want it. With 5 pts all wanting pain meds first thing in the morning, I don't have the luxury of assessing them first then going to get their meds. The next thing I do right after report is to try to be the first in med room to get meds as I hate standing in line and if I start late, it puts me behind all shift. I assess after it's pulled, and when I'm in their room, then give as long as their vitals are stable. If for some reason, it's that 0.5 pt that declines a pain med, I have no trouble finding a witness to return it to the Pyxis. It's usually unopened anyway. Where I work, we're encouraged to always have pain meds in hand before going to see a pt as opposed to seeing them, them asking for it and you having to run to med room to get it. Nobody has ever given me grief for being a witness nor have I ever given anyone else. I just make sure what I'm being shown corresponds with the Pyxis screen.

I'm sorta responding to your second to last paragraph...

(reply to Jade's post, *shucks I should have quoted it*)

You didn't include the type of unit that you work on, and I am curious. The only two areas that I can think of off of the top of my head where this could be acceptable are burn and ortho surgery. This would never fly on my med surg floor.

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I'm waiting for the day when this here ER runs out of Dilaudid, taxi vouchers and turkeys sandwiches!

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