Gericare25

Well I started a per diem home care job in March and only told a few coworkers. I recently decided to go per diem at my full time job. Today the scheduler overheard me talking about my home care job and got pissed saying she thought I went per diem to be with my family more and not “just leaving us to work another job”. I went per diem for my mental health because the work environment is toxic and I can only handle so many days there anymore. So while it may not seem like a big deal, there are coworkers, schedulers, management, etc that will treat you differently or feel you’re less committed because you have another job.

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.

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!

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.

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!

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.

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!

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!

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! :)

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

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!

These are bottles we pull and use only for one resident so none of the med should be used while in the med dispense. It is a strong narcotic and the largest dose which would be very large would be 1mL at a time. Usually we give 0.25-0.5mL of the med but again we only do that after we pull the bottle under the resident's name. Then it goes into our locked narc box on the med cart. I also don't buy that the med could have just evaporated as it is a very large amount of liquid and I don't believe either bottle had been in there for a long period of time. Normally I wouldn't even be so worried since there were so many counts between me restocking with the nurse and them finding the issue but when a narc comes in from pharmacy we take two signers to verify. The sheet they pulled from that night only shows the nurse I restocked with as a signer so no backup that the bottle had anything in at that time. So either someone forgot to sign the paper when they checked in meds with her or she failed to get a second person to check. In which case she is really in the hot seat as she has also participated in a lot of shift to shift counts as well.

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!

I actually don't do the shift to shift count as I work as a floor nurse and not the supervisor. Apparently the supervisors have not been looking at the liquid in the bottles and only that there are bottles of the right count in there. This is obviously going to change now! This is why they are having such a hard time pinning down what happened!

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. No sign of spillage according to the higher ups. We do not give from the bottles in the med dispense. If we need to pull a bottle we get an auth code from pharmacy then pull and use the bottle for that resident only. They come with the red tamper wrapped around the lid and bottle. The higher ups showed us the bottle and the sticker was completely removed but the RNs that counted said the tamper sticker had only been "pushed down" so not sure about that detail. The bottle was not stained at all and usually they are very stained from laying in the drawer. When I mentioned that to them they opened the bottle and showed me that there was a red film caked at the bottom of the bottle so there had obviously been med in there. One nurse is convinced it evaporated but I don't know how 15mL could have. The odd thing is the night that we restocked the morphine, we had called pharmacy because dayshift had pulled a bottle and it was so stained it was impossible to count. We had asked if we should waste and pull the other bottle or if they could send an empty one. They told us to hold the med until morning and they would send a new bottle specifically for the resident and then we could waste the stained one. The resident ended up passing away that evening so no new bottle was needed.