Pyxis undocumented waste

klone, MSN, RN · Jun 2, 2018

You need to ask your manager or the person in pharmacy who is in charge of your Pyxis.

meanmaryjean, DNP, RN · Jun 2, 2018

I would not poke that particular bear. Likely your preceptor has handled it already.

JKL33 · Jun 2, 2018

Not to get all instructive and I'm sure you've figured this out anyway, but in case you haven't - - try very hard to get in the habit of wasting immediately; as in, before you leave the dispensing machine. Use your wok phone to call your charge nurse or another coworker to witness if no one is around when you need to perform a waste. Handling of controlled substances is something that employers have taken a very hard line about in the current environment.The days of "I'll do it later" are gone. So that's my encouragement for you adopt careful practices with regard to this. :)

Take care~

nicunursecourt · Jun 3, 2018

Yes, I completely agree that it is so important. Thank you for your input. We do not use controlled substances frequently on our unit and most of ours are oral medications delivered by pharmacy that require paper sign off. I am feeling so guilty and it is definitely making me aware of ways to better implement safe practices.

marienm, RN, CCRN · Jun 3, 2018

Not quite the same issue, but I was called into my manager's office based on the discovery (during a chart audit of a now-discharged patient who had been hospitalized for 2 months) that I had pulled one dose of an oral narcotic for this patient but didn't scan it. So, a med error, since the med was never charted. Nothing adverse happened to the patient...it's not even like another nurse came along after me and gave a 2nd dose too soon. Also, they were concerned about diversion but I have otherwise never had any issues so I don't think they were really *that* suspicious.

Anyway, I had to go down to the records department and do a chart correction, and I had to write an incident report on myself, and that was basically the end of it. No, I did not get fired or lose my license. Granted, maybe my hospital and manager were lenient? But realistically, I don't think it makes sense to fire a nurse you've paid a lot to train because of one med error that caused no actual harm.

I would maybe ask your preceptor what to do or if she already handled it. (If it was pulled under your name, she might not have been able to waste it.)

rx3500 · Aug 9, 2018

Hi, I am a pyxis manager and get this question often. Once a patient has been discharged, you can add the patient back into the system, and use this to return meds to the return bin , but the documenting the waste may not be an option because the initial transaction under the patient was under a different profile. The return will show up in the reports if audited. Documenting your waste in the medical record is an important step because it will show the path of the narcotics use. Make sure that you have a witness and have them document witnessing the actual waste. In this situation I would have the charge nurse or supervisor be your witness. Writing a memo on the situation, and having the witnessing party sign as well is a good way to prove the transaction. Keep a copy. In pyxis the option is there to document waste when pulling the med to avoid having to remember it later. Definitely remember to document this in the patient chart for tracking purposes. Additionally reach out to your pyxis administrator for guidance. They will be able to help. Never be afraid to admit the mistake, supervisory awareness, self volunteered looks better than not mentioning it at all.

psu_213, BSN, RN · Aug 9, 2018

self volunteered looks better than not mentioning it at all.

I agree. Make sure it is dealt with and the waste is recorded in the chart, Pyxis, somewhere. I understand the idea of 'don't poke the bear,' but given the current opioid epidemic, it would not surprise me if a hospital started going back (years?) to look for wastes that didn't occur. In addition, the hospital may be inclined to look more closely for unwasted meds if they have some sort of diversion issue come up. It will be tough for you to explain it away , even if your situation has nothing to do with the issue that brought up the closer scrutiny of non-wastes.

JKL33 · Aug 9, 2018

Documenting your waste in the medical record is an important step because it will show the path of the narcotics use. Make sure that you have a witness and have them document witnessing the actual waste. In this situation I would have the charge nurse or supervisor be your witness. Writing a memo on the situation, and having the witnessing party sign as well is a good way to prove the transaction. Keep a copy.

Maybe I'm not understanding. WADR, of what use is any of this now? There is no actual witness, no actual waste, and no transaction for anyone (including a charge nurse or a supervisor) to witness. There is no way to prove the transaction 1-2 months after it happened.

Who would vouch for the truth of a statement someone writes two months later without any independent knowledge that it is true?? Not me. A witness may verify their signature, but that in no way proves any transaction.

Also, when you say to document a waste in the medical record, do mean in addition to using the appropriate "waste" function in the pyxis system? How would that work? We've already physically wasted the medication at the pyxis (and had that step witnessed). Now is that 2nd RN also supposed to document a witnessed waste in my patient's medical record? Because if not, my "documentation in the medical record" would just be me saying that I performed a witnessed waste of the non-administered portion (but again, if we can't "trust" the pyxis record then there is no one to vouch for what we've documented in the medical record unless 2nd RN documents in my patient's record that they witnessed my waste of X.)

In the past it's been possible to document a proper waste in dispensing machine after the patient is discharged - not that uncommon in the ED. Haven't tried it for awhile though because I waste in real time come hell or high water now.

psu_213, BSN, RN · Aug 10, 2018

Also, when you say to document a waste in the medical record, do mean in addition to using the appropriate "waste" function in the pyxis system? How would that work?

I once pulled Ativan on a seizing pt. Some was used, some not. The ED pharmacist actually saw me waste the unused part, but for whatever reason we did not document the waste in the Pyxis. I reminded her a few days later that we had to document the waste. The pt was already out of the Pyxis, and that encounter could not easily be reactivated. I wrote a note in the pt's chart that I had wasted 1 mg of Ativan, witness by Sally Smith, PharmD. She they wrote a separate note indicating that she witnessed me wasting the med. It may not be the preferred method, but if anything comes back to me, I can direct them to the pt's chart.

I do agree, you will (almost) never get someone to sign as a witness for a waste he/she did not actually, well, witness, so you will not be able to get the CN or supervisor to act as witness. To the OP, talk to your preceptor. Find out if he/she has done anything with the situation. Make sure that the preceptor will waste it with you, and then speak to the pharmacy about how to go about documenting a late waste.

rx3500 · Aug 10, 2018

I am unsure if you read the initial issue. She forgot to waste in pyxis. So months later she is concerned that in an audit she may have to explain where the remaining drug not utilized went. My suggestion was for future transactions. Audits are usually done monthly, and if she has not been audited yet, the likelyhood is slim. I work with NCIS and controlled substance inventory boards often to resolve possible cases of diversion. It's always better to disclose and annotate in memos the situation. One occurance is not enough to terminate. It's the trend we look for. I see these situations all the time and I keep precise records of questionable transactions. Documenting things as soon as possible and corresponding with the appropriate channels is more likely to justify an honest mistake.

JKL33 · Aug 11, 2018

Yes, I read the original issue. I understand what you're saying; on first read I didn't follow through the instances of present situation vs. future.

But I'm still going to ask for clarification:

Documenting your waste in the medical record is an important step because it will show the path of the narcotics use. Make sure that you have a witness and have them document witnessing the actual waste.

I will ask again. Are you suggesting that, as a matter of routine every time a medication is wasted, I should document in the medical record that I wasted something and that the waste was witnessed by Jane Doe, RN? And Jane Doe should also enter that patient's medical record and write a note that they witnessed the waste of X mg of this med?

That makes sense and I'd go along with it. However, it's a step that largely fell by the wayside once everyone began using medication dispensing cabinets and there existed the functionality to witness at the machine. So it would be a great big "roll-back" in lots of places, to revert back to documenting a waste in the record itself/eMAR. Especially since the advent of being incentivized to do everything as fast as humanly possible.

I can see in thinking through this that pyxis' record of transactions has sort of been allowed to stand in for proper legal documentation, when in reality the pyxis transaction record is simply an administrative tool associated with pharmacy. Hmm.

In this situation I would have the charge nurse or supervisor be your witness. Writing a memo on the situation, and having the witnessing party sign as well is a good way to prove the transaction. Keep a copy. In pyxis the option is there to document waste when pulling the med to avoid having to remember it later. Definitely remember to document this in the patient chart for tracking purposes. Additionally reach out to your pyxis administrator for guidance. They will be able to help. Never be afraid to admit the mistake, supervisory awareness, self volunteered looks better than not mentioning it at all.

Okay, yes, I see what you meant. It may be wise for anyone who realizes they have forgotten to waste, to approach their manager ASAP and write out a memo about the forgotten waste documentation, noting that it was indeed witnessed and the name of the RN who witnessed it. And yes, the manager can witness someone writing all of this on a piece of paper. By "prove the transaction" you were referring to the transaction of writing the statement, not the transaction of having wasted anything or witnessed any waste.

In pyxis the option is there to document waste when pulling the med to avoid having to remember it later. Definitely remember to document this in the patient chart for tracking purposes.

I understand now you are saying to "waste" at the pyxis and then also document wastes in the medical record.

Everyone should utilize the pyxis waste function in real time - right then when removing the med and prior to administering it or even leaving the area with it. Actually I think it is the only way the pyxis waste function can be used legitimately, since, if the witness is not present for the whole removal/prep/waste procedure then the witness really can't be sure of what they're witnessing.

It bothers me the way nurses are threatened (not just suspicious actors but entire staffs) and treated because of something someone did somewhere sometime in the past - meanwhile the actions that management suggests or puts into policy most certainly aren't foolproof in plenty of places.

Example:

The right way to do this these days would be to call witness to the med cabinet. Remove med, draw up correct amount, label it, remove remainder, verify amount, waste it, and have the second person sign the waste in pyxis. (plus the added step being suggested here of both then going separately into the medical record and documenting the waste). Remember not to properly dispose of empty vial because it is still needed for scanning at the bedside.

What is totally accepted and advised in many places, instead, is: RN removes med, goes to patient room, administers med and documents that. Starts looking for someone with whom to waste the remainder. Once someone is flagged down, go to pyxis together, perform a "witnessed waste" [of whatever liquid substance in whatever amount is in the vial]. Kinda funny that it would upset an apple cart if this procedure wasn't followed. I mean, it is actually meaningless and proves nothing.

So. Option 1 is what is prudent and complete. But it's not what most places advise or would want because it hogs nursing time. So. Do it the second way, and if you don't you will find yourself the subject of a witch hunt.