Where Did That Medication Go?

Pill counts, drug diversion, and discontinued medications never returned to the pharmacy are some of the issues that can happen in the healthcare facilities.

 Frustrating as it can be when a nurse expert tried to review medical records and compare with the pharmacy records, it is very important.  One of the big issues, is when reviewing the pharmacy records are not with the medical records.  Pharmacy is kept separate.

 For example, when medications are received, there is usually a documentation sheet with the medication.  It is important when the documentation matches the medication received.  Good example there are many look alike medication and pharmacies do make mistakes.  However, if there are errors marked on the documentation sheet, such as only 25 tablets are received yet in the header on the punch card and sheet state 30 were sent, this could flag an issue.

 In one case I had, there was a diversion of 360 Vicodin tablets that were never administered to the patient.  Sadly, the patient was none verbal due to a motor vehicle accident and he was in the facility for total care.   He depended on the staff for all his activities of daily living (bathing, personal care, oral care, feeding, etc.)  and medical needs.  Vicodin tablets look like other generic stock medications like acetaminophen and could easily be switched by dispensing staff.

 In this case, the medication audit revealed when the pharmacy records were compared to the Medication Administration Record (also called the MAR), none of the withdrawn Vicodin from the Control Substance Documentation were charted as administered to the patient.  In fact, the staff marked on the Control Substance Withdrawal Documentation, the medication was withdrawn and dispensed to the patient’s mother.  Now, did the staff give it to the mother for her use or for her to dispense to her son?  If giving to the mother to give to the son, then why didn’t the nursing staff as required dispense to the patient.   Either way it reflected medication diversion. 

 In another situation a night nurse was found by other staff “sleeping” and it was not possible to wake her.  After further investigation of the situation, it was discovered there were patient medication capsules filled with sugar in the medication cart.  The night nurse had opened the patient’s capsules (Librium), consumed the contents, refilled the capsules with sugar and replaced the capsules back in the medication drawer to be administered later.  There were progress notes by other staff that the patient had not be well at certain times and the medication being administered to her was not effective. 

When It comes to medication reconciliation, I have many situations to share, so watch for further blogs.  These blogs are to “trigger” your thoughts when medical record reviewing.   Please check out the other blogs on the website.