Omnicell error

[whichone'spink, BSN, RN]

Seeing the Pyxis error post has made me extremely wary about events that have happened to me in the last 2 days. So, I had a patient who was an ICU level patient. I completed their PACU recovery in the ICU room she was assigned to, which is common for me to do on weekends. I recover inpatient surgical cases in their inpatient rooms no matter where they are, as the rules state I can go anywhere that has at least one other ACLS nurse on staff.

During the patients time in my care, I pulled out a vial of fentanyl, intending to give it mainly for blood pressure control, at least until I got clevedipine from the pharmacy. I never gave any of it because by the time I pulled out the fentanyl, someone from pharmacy handed the clevedipine to me. Unfortunately I popped the top off and had to record this as a waste. Which I did with another ICU nurse, and flushed down the sink. Here's where it gets scary.

Monday I get a call from my supervisor saying there is a discrepancy. Apparently I recorded the waste as 0 mcg given instead of 100 mcg. So it looked like a whole vial of fentanyl (which contains 100 mcg) was missing! I've made typos before, but I don't know how this one went through. To make matters worse, after talking with pharmacy, my supervisor tells me I have to re-record the waste with the ICU nurse I wasted with. I couldn't exactly remember who it was and went back to ICU Monday evening to find out if the two nurses I narrowed down to were working. They were not.

What an awful night Monday night was. I only got 3 hours of sleep, and I couldn't bring myself to have a shower. I was in the same clothes I was in Monday. Tuesday comes around and I go back to the ICU, since one of the nurses I narrowed down to was working again. Unfortunately she didn't remember if she had wasted with me or not. So I call the pharmacy and after getting somewhat of a run around, find out that no second witness was recorded for that waste. Great, so there is no record of a second name and I'm not 100% sure who wasted with me. I left a voicemail with the pharmacy manager, which my supervisor suggested, to get advice on how else I could fix this issue. She never bothered to call back, yesterday or today for that matter. So I went back Tuesday evening, and tried again to have the first nurse reconcile this with me. She insisted she didn't recall wasting anything with me, and understandably was reluctant to help me re-waste. Thankfully, I did manage to find out the second nurse who could have helped me waste was working that night. So once again, I leave and come back in time for the night shift. I approached the second nurse, and thank God, she remembered wasting the fentanyl with me. So I logged into the Omnicell, pulled up the list of medications that needed to be wasted, and had to manually search for fentanyl since it didn't show up. I did that, put in the dose administered (0 mcg) and dose wasted (100 mcg), and she signed. I hope that takes care of it.

Except now I am worried that it's far from over. And I'd be justified in feeling this way. For one, it looks extremely suspicious that the fentanyl is recorded 2 days later, and that it took more than 24 hours to resolve. I've forgotten to chart narcotic administrations due to non-working barcode scanners, and I was given 24 hours to resolve the issue. In addition, I emailed my supervisor about the actions I've taken, and I've not received an email or phone call back saying I'm in the clear. The pharmacy manager also never bothered to call me back either. I am extremely worried when I go back to work on Friday, I will be pulled into the office, subjected to a strip search and drug test, and suspended for at least 2 weeks. I've already looked through the attorney referrals on the TAANA website, and there are no attorneys listed for the state of North Dakota. So I'm not even sure who I can turn to if s*** goes down, which it will.

I'm just trying to be proactive here. I've made errors before with controlled substances, and no further action was taken. I once found a vial of ativan after washing my scrubs, and the label was washed off. I knew it was ativan because it had the consistency of ativan, not any other medication. I went back to work, resolved the waste with the charge nurse, and flushed it down. There have been many times I forgot to return vials or pills at the end of my shift, and I would go home with them still in my pockets. I always went back immediately, and returned them to the Omnicells I pulled them from. Sometimes on multiple floors. But this is the strangest one yet because how did a recorded waste of 0 mcg go through in the first place?! I'm just worried this could be turned into a Kafkaesque nightmare for me because of a f***ing human error.

[BeenThere2012, ASN, RN]

I completely understand that you are worried. It seems to me though, that you took care of this situation as you should have. First and foremost, write EVERYTHING down that you remember about what happened including names, dates, who you spoke to...similar but more detail if possible to what you posted here. Depending on your relationship with your supervisor, why not ask for an appointment to sit down and discuss your worry? Not sure if others may disagree regarding putting more attention to this than is necessary, but assuming this is the whole story (no offense intended), then there shouldn't be any problem.

And now Im going to yell at you like a Mom...STOP ACCIDENTALLY TAKING HOME MEDS.

It has happened to many of us at one time or another, but you have done it several times and this could look suspicious in itself. YOU MUST change your habits regarding how you handle the vials. Make a mental note and immediately change this habit of putting them in your pockets.

My main point to you is that in this day and age, we all must be much more consistent with following P and P's to the letter when it comes to narcotics. Whatever may be the usual culture in your hospital, such as waiting until after giving a dose to document wastes for example, stop doing things like that. Every place I have worked, has the Pyxis ask you if you intend to give the whole vial when taking out a narcotic. Right then and there when you know what the ordered dose is, you need to get the second nurse there to co-sign the waste. In ICU's and/or emergent situations, sometimes that is not done. This is the only exception I would accept for documenting actual doses given until a later time.

Also, I did understand your rationale for wanting to give Fentanyl in an attempt to bring down an elevated BP, BUT, if this was not written in the order as a PRN indication to give Fentanyl, then you could get in trouble for this as well.

Good luck to you. Sorry to "yell" but as a relatively new nurse, there are so many things to learn, and one of the most important is that you need to nick bad habits in the bud before they lead to errors and then bad situations for you down the line.

[cayenne06, MSN, CNM]

I brought home a half full, non-wasted vial of dilaudid once. Boy did that wake me up. And I agree-It is scary to think that a simple typo or machine glitch could put our livelihood on the line.

I do think that the amount of narcotic errors you listed above might raise red flags (and rightly so) with employers. When I brought home that dilaudid, I examined my practice and made changes to reduce the risk of repeating the error. I have not made any other narcotic errors as of yet, knock on wood. Not saying it won't happen; just that I was able to identify areas where I could improve my practice.

Re: auto logout. The pyxis I used would automatically log out after 60 seconds. However, we were explicitly told that logging out is our responsibility. If someone was able to get in to the pyxis because we left the med room without signing off, we could face disciplinary action. Similar to how it is our responsibility to log out of common use computers to prevent unauthorized access. An open pyxis means that you have left controlled substances unsecured.