I am an RN who learned from my supervisor Friday that there was one tablet of Percocet missing and that the count was off after I last entered the drawer. She said the off count was noticed by the next shift when the nurse went to pull the same med.
My supervisor asked if there was anything unusual that I remember about the last administration of medications. I did explain that the larger Percoset tablets were placed in a smaller cartridge so that many of the blister packs were separated into individual packs so they could all fit in the smaller space. I also noted they were in the cartridge on the outermost edge as opposed to a cartridge in the center to prevent possible issues.
I have never had this issue before; I believe it is possible that one tablet may have dropped while removing all of the tablets to count them or when putting them back by either me or the nurse on the next shift.
I have been asked to write up a statement for the investigation. What should I say and what shouldn’t I say? It is possible that someone may have found the tablet and placed it on top of the medication cart, and then when pharmacy came in, they may have picked up the tablet and taken it back to pharmacy. Should I ask pharmacy what their procedure is if they find a tablet? What can I expect? What should I do next? I would like to know the best way to proceed, what are the most likely outcomes, and how I can protect myself?
Dear Nancy replies:
You are in a difficult situation and need to immediately retain a nurse attorney or attorney in your state who works with healthcare providers to help you with this matter. The required statement must be factually and carefully drafted and your attorney can help you with its composition.
The situation you are in underscores the importance of handling narcotics strictly pursuant to hospital procedure and the importance of signing off of any automated medication dispensing equipment when you have pulled ordered medications from their respective drawer or drawers. It also emphasizes the importance of voicing concerns with your nurse supervisor and others designated in hospital policies when the narcotics drawer you have access to appears different than it should be.
The investigation is just the beginning of what most likely will be many phases to this incident, and the attorney you select can represent you as they unfold.