Second OpinionsNarcotic counts

Narcotic counts

During drug inventories, I've seen one nurse come in early and count narcotics, then a second nurse come in later to count and co-sign. Shouldn't the count always be done by two nurses at the same time?

Started by: susan berg (Other) at February 16, 2013 (11:24 am)

Comments and Responses


Just answering the comment made by Barry Friedberg ;beware of Ketamine!Is a addiction substance too and probably worse than opiates.And more:narcotic is not appropriate,we define opiates and hypnotics just to be more precise and of course otherwise we define "controlled substances".Controlled substances must be controlled no matter which are the regulations.Claudio Melloni,Md,Anesthesiologist.

Claudio melloni (Anesthesiologist/Nurse Anesthetist) at February 21, 2013 (12:25 pm)

I think everyone should check the DEA regulations regarding this matter. Especially Mr. Shorr.

patricia o. (Other) at February 21, 2013 (11:00 am)

1. In our facility two RNs count at the beginning of the day and at the end of the day.
2. Any time narcotics are added to stock, two RNs first verify the existing count and then add the drugs and co-sign.
3. Narcotics are signed out to each anesthesiologist at the beginning of the shift and before they leave, they reconcile their records with an RN who co-signs with them.
4. A word of caution... it has been my experience that an RN who wants to divert drugs will find a way to do it. I have worked with two who were very clever in how they did it.
5. Two RNs should verify that what was ordered is actually what is being put into stock (look at the DEA form). Also, when counting, make sure that the RN who is writing actually writes the amount that is being told to them. These are just two of the ways we have had narcotics diverted.

Micki Joseph (Director, Surgical Services/Director of Nursing) at February 20, 2013 (8:31 pm)

The Narcotics should be counted at the beginning of the day and end of the day by to licensed staff members. One person should say how many of the drug with the other member checking what is recorded in the marcotic book. We always make sure there are two RNs or an RN and Doctor to count our narcotics. We also have a quarterly audit by a pharmacist.

Debbie Holtorf (Director, Surgical Services/Director of Nursing) at February 20, 2013 (7:10 pm)

I agree with most of what is written above buthave a few other perpectives as a pharmacy consultant to many facilities.

> True in fact that each state MAY vary regarding the documentation expected and the frequency etc., but the basic need to do an attestation at the beginning and end of an ASC day is constant.

> The count should be done by two licensed persons OF THE FACILITY. It is our opinion that the facility's own staff shall assume the attestation responsibility. Having outside contractors, i.e anesthesia providers, does not seem to adequately assign responsibility, in the final analysis, under the purvue of the facility leadership

> Importantly, when/if there is a transfer each AM to the anesthesia providers, there should be a record of who took what and the quantities, that are signed by both the anesthesia provdier and a member of the nursing staff. Similarly, this should be re-entered ina log, with signatures at the end of the day or return from the OR for the day.

> The Biennial Inventory, due in odd years on or about May 1 (i.e. May 1 2013) is a routine and important probe by controlled drug overseers from the state or DEA. These counts should be in place with the advice and assistanmce from your pharmacy consultant.

> We have a card posted on each of our controlled drug cabinets:



(860) 604 0014

It's prettier than that this!! But the idea is that the signer should verify only after sighting the acutal product and not just accept called numbers

> If you use both a safe and a controlled drug cabinet, the safe should have limited access or that too would have to be counted twice a day (or three times if a 24 hr service).

> Safe combinations should be changed on the departure/ resignation of a previously-authorized individual

Sheldon Sones, R.Ph., FASCP

Sheldon Sones (Other) at February 20, 2013 (5:23 pm)

Number one in a counting policy is to check with the DEA or State licensing agency to obtain the state requirements for controlled substances.

I have to agree with everyone else here, two people who are licensed to administer the drugs should be counting them. Once at the beginning and at the end of the day, or end of the shift. If you run a full time 24-7 facility then every shift change must count. To make matters simple, when someone is going off duty, a count must be done. That way, there is no problem should 8 hrs later it be determined that the count is off and someone left.

A count should be done anytime someone suspects a discrepancy in the inventory. This would happen when then use the tally system, and one is short a dose when they are removing the dose to be administered.This count should involve someone from a supervisory position in the department.

Pyxis is a good invention, and may stop pilfering, In my years in nursing, I have yet to see the pharmacy tech remove the waste bin and count and verify with the machine. Most have been seen simply dumping the contents into a red bin near the machine.

Tackle boxes are great and time saving ideas, my last place of employment we utilized small wallet boxes. Frequently they were dropped and the narcotics smashed inside. The box is simply dried up and rinsed out of the watery substances, and the count sheet reflected a broken ampule witnessed by another person. I always felt it should be sent to pharmacy in a red bag by the person who had the mishap and substances verified. And yes, pharmacy techs have a meter to determine the amount of drug in a syringe.

When new narcotics are received into the system, the person bringing in the new stock must stop and get another licensed professional to witness the add. Never should a lone person add stock back to the controlled substances. I have seen stock go missing in transit, it was not missed because no one entered it into the receiving stock.

Years of practice in nursing has shown me a lot of the failures of the systems we all put in place to prevent them. As I have always said, if a person wants a substance, he/she will get it, no matter what safeguards are in place.

David K. (OR Manager/Supervisor) at February 20, 2013 (4:54 pm)

Two licensed professionals should count at the beginning of the day and end of that shift period. Then there are other times that needed to be accounted for such as during the night.
The last place I worked used pyxis for anesthesia in each OR room and pyxis in the inner core for nursing staff. This was best method to control medication and narcotic usage.

H. Glinski (Other) at February 20, 2013 (3:05 pm)

We agree that 2 licensed persons, MD, ARNP, CRNA, PA or RN should perform the count at the beginning and end of each day. Just as important is the witnessing of waste.

Wasting should also be performed by 2 licensed people and co-signed.Many professionals with drug problems get their "fix" by stating certain amounts of the drug were wasted when in actuality they were not.

Debbi Conn, RN, Licensed Risk Manager
Universal Healthcare Consulting

Debbi Conn (Administrator/Director/Manager/Owner/Exec. Officer) at February 20, 2013 (2:53 pm)

Counting is irrelevant when non-narcotic anesthesia is used.
Only 15 years without narcotics in >3,000 pts!

Measure the brain (BIS/EMG)
Preempt the pain (50 mg ketamine 3 minutes pre-stimulation)
Emetic drugs abstain (no narcotics/inhalational agents)

Numerically reproducible. Not rocket science.

No diversion issues either :-)

Barry Friedberg (Anesthesiologist/Nurse Anesthetist) at February 20, 2013 (2:22 pm)

Narcotics should be counted at the beginning and end of the day by 2 RN's. They should also be responsible for distributing and returning of narcotics throughout the day.
We use have tackle boxes with preset narcotic medications in each box for every room. This standarizes narcotics distribution for each room and is helpful for restocking at anytime

R. Borrego (Medical Director/Chief Surgeon) at February 20, 2013 (1:38 pm)

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