Pyxis Discrepancy

Nurses General Nursing

Updated:   Published

Specializes in Ortho/Neuro Trauma.


Hello everyone, I’m looking for advice.

This is the first time this has happened to me and I don’t know how to handle this situation.

I just got an email saying there was a med discrepancy regarding a narc. The report says 9/30 1615 I pulled 10mg of oxy. The count was verified at 26. And it’s shown that I administered it to the patient at 1618. Next, another nurse comes in to pull 5mg oxy and the count is off by one. The count should have been 24, but the nurse who came in after me counted 23. Then the charge nurse came in and settled the discrepancy as a miscount, but according to the report that missing oxy was never added back to the Pyxis so it technically is not a miscount.

I did not drop one or take an extra.

And it’s very odd that I saw both the charge and the nurse and had multiple conversations with them through the remainder of the shift, all casual and friendly, but no one brought up that an oxy was missing. No one mentioned anything or brought up anything to my attention or asked me questions. I had no idea that the count was off until the next day, on my day off I just happened to check my work email and saw an email stating there was a discrepancy found by the pharmacy on 10/1.  

Has this happened to anyone? This is so confusing to me. I’m a new grad and was taken off orientation early due to lack of staff. I’ve been working there for 2 months and I’m not sure who to ask since my old preceptor is on vacation. Any advice would be greatly appreciated. (Sorry for X-post)

Specializes in Psych (25 years), Medical (15 years).

From what I can tell, RN87, the count was off, so the charge nurse righted the number saying it was a miscount.

When the charge nurse righted the number, the correct number of oxy pills should have been entered. That process should have taken care of everything discrepancy, so something is awry.

The charge nurse is responsible for the error, if only clerically. If there is actually a missing oxy, then an investigation needs to take place.

I had a similar situation involving an alprazolam tab which was never found and had to do a successful urine drop. I don't recall the particulars.

Whenever there was a discrepancy with a controlled substance in which I had to rectify the count, I always kept a copy of the rectified pyxis print out.

Good luck!

"It sounds like the two of them messed something up. This doesn't involve me."

Specializes in Psych (25 years), Medical (15 years).

Ooooooh yeah JKL.

I went back and read that RN87's count was 26- at least two oxys had been taken out before the discrepancy occurred.

You are so sharp and I love you for that.

Edit: Oops. Wait a minute- 10mg RX, oxy 5's. Shouldn't there have been 24 oyxs?

Specializes in Med/Surg, LTACH, LTC, Home Health.

Yep. In my situation, when I pull the meds out of the drawer to count them (using adjacent cartridges as a table), one of the little devils slid down between two cartridges, creating a discrepancy for the one coming behind me. In my case, the next nurse just happened to be...drum roll...ME!! I volunteered for urine testing, which was denied because there are those who’d rather assume you’re guilty as opposed to receiving proof of your innocence. So, without the test, no action could be taken against me. Go figure...

Anyway...From that moment on, I placed the meds on top of the Pyxis to perform the count, carefully returning the meds to the cartridge two at a time. That medication wasn’t found until the pharmacist came to inspect a ‘failed drawer’ that couldn’t be recovered using the ‘recover drawer’ feature. 

Sometimes, **** just happens.

Specializes in Ortho/Neuro Trauma.

Thanks everyone. I correct the numbers in my post, I wanted to change the info up in case someone I work with happens to see this (which is rare but you never know). Everything is correct.

Specializes in Psych (25 years), Medical (15 years).

Thanks, RN87.

I thought I was having a Senior Moment there and was going to have to give up  working as a nurse.

Wait a minute- I already did give up working as a nurse.

Carry on.

The spirit of my answer remains the same. That is, remain unprovoked. Don't start talking too much, making guesses, panicking, apologizing, etc. Maintain the attitude, "I am uncertain how this involves me." Don't have any extra conversation about it and stay in business mode, not freak-out mode.


Specializes in New Critical care NP, Critical care, Med-surg, LTC.

I also wouldn't worry about it unless you're specifically approached about the situation. When the charge nurse and the other RN entered/resolved the discrepancy, someone had to enter a note as to how it was resolved. Since you were not involved in that process, nor were you sought out at the time to address it, I would not assume you have any responsibility. 

Specializes in Medsurg.

Don't worry about it. Whoever fixed the discrepancy after you would have had to make a comment to fix it. 

Specializes in Ortho/Neuro Trauma.

Thank you to everyone helped eased my anxiety ? 

A little update: the nurse and the manager found the missing oxy and all is accounted for. Crisis adverted LOL

Specializes in retired LTC.

RN87 - TY for the comeback. Nice to know that 'all is well in the kingdom' for you.

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