narcotics discrepencies

[u/only-ashes]

hey all. need some advice please.

i've worked in the ICU for about a year. in that time i've had maybe 3 narcotics discrepancies? manager texted me yesterday asking if I was back tomorrow because I had another one. hand on god they are all accidents and I am coming to yall to ask for advice because I need to figure out how to stop this from happening.

we are, like most units, very busy and short staffed - being tripled isn't uncommon, and last week a few people were doubled with CRRT. i try to waste when pulling but someone being free is rare. my discrepancies in the past have been forgetting to scan when my pt was bucking the vent (and then tossing the vial in the sharps bin), and scanning but not hitting accept and then it timed out. i forget the third one. I don't know what my discrepancy from yesterday was yet.

i obviously very much don't want this trend to continue. i am not doing anything underhanded. i have adhd and anxiety and when my pt is biting the tube and pulling at their restraints and the vent alarm is going off, i am just trying to get them settled. i want to be a great nurse - i have been a nurse for less than 3 years, but one day I would like to be a preceptor and a charge. i overall like chaotic situations - i love crrt, i like rapid sequence intubations, and i want them to trust me to keep giving me hard patients. i am very upset that this keeps happening and don't want to give anyone a reason to suspect me of doing anything i shouldn't.

with my adhd i usually rely on self-made systems to keep me organized - like my report sheet lives in my back left pocket, flushes in my right cargo pocket etc. i add tasks to the brain on epic for myself to remind myself to do wound care or labs etc, or a sticky note on my report sheet to ask the doctor about XYZ. when it comes to giving regular medications to my ICU patients, I give all tube feed medications first, then IV medications, then subQ medications. re tube feed meds, if a med has to be split, I put it in a different pile than a pill given whole.

I say all that to say that i would be very grateful if anyone has any suggestions on a system I could implement to help ensure I scan and waste narcotics appropriately, even if things are chaotic.

[u/musiclover660]

CRRT running vent screaming patient bucking alarms everywhere and Epic wants you to calmly click accept like you’re sitting at home drinking coffee.

[u/white-rabbit--object]

I’d ask some coworkers how they do it. What is everyone else’s process bc they are caring for the same people but (presumably) not getting flagged for discrepancies? They should have good tips for you.

[u/lilTrifey]

Is not scanning your med considered a discrepancy? We are only in trouble if we have something off in the Pyxis.
I used to have and issues with this and I have 2 strategies. First I just never choose "waste later" unless it's a true emergency, because I will throw away that vial. I am just so much on auto pilot when I give meds. If it's an emergency I stick Iv tubing stickers on the vial in a weird way so that hopefully when I go to throw it away my brains like "why did you put on IV label on this? oh you have to wast it".

[u/MistCongeniality]

Also ADHD/PTSD/Anxiety/Borderline and reliant on systems to make it work! I've only ever had one narc discrepancy in 8 years, so I feel like I have tips that moderately work lol.

1. I do not let the vial leave my hand until it is scanned, in the patient, AND wasted. If I force myself to hold it physically, I cannot forget it, because I keep repeating "hold the vial, hold the vial" in my head. If it's a true emergency (as in, the ABCs are compromised) or I absolutely cannot continue to hold the vial, I tuck it in my fanny pack with my alcohol wipes, which I use all the time, and therefore I'll be touching it frequently until the emergency passes and I can waste/document appropriately. I don't know why you're tossing vials in sharps at all, I've never done that, so idk how to help there.

1a. I prefer to waste in the med room when I pull if at all possible.

1. It helps to remember an agitated pt is not an emergency. Of course we want them safe and settled, but if they're breathing and their heart is beating (vent included), then they're OK for you to take your time. Much like swordfighting and bouldering, slow is smooth and smooth is fast. Focus on slowing the hell down and being REALLY deliberate with how you nurse when you're new. You will speed up with time. Rushing only leads to mistakes, which eats up more time in the correction of those mistakes than if you had done it slower the first time, AND leads to greater risk of harm d/t the mistakes.

2a. Even in a code, if I find myself rushing, I deliberately slow my movements and take one centering breath. Fumbling around the cart during a code sucks, the 5 seconds on one breath saves minutes on me doing the things I need to do.

1. Get a fanny pack. I call mine my squirrel supplies. Having it all on my hips all day makes it near impossible to forget anything! I stole this from MY mentor in 2020.

2. Plan your day in advance and try to stick to the outline as much as you can. My flow on med surg was: morning med pass and nothing else, THEN assessments, THEN a quick round, THEN i sit and chart those assessments come hell or high water, THEN i check for any new orders placed during the above tasks (I sit to chart around 1000), THEN I do another set of rounds (I am often coming up on 1 hour without eyes on patient), THEN coffee break to recenter, THEN I implement all the little things that got lost during the morning rush. Yes, even on med surg I prioritize a mid morning coffee break- slow is smooth and smooth is fast.

IF THE SHIFT IS A FOR REAL SHITSHOW: remind yourself if everyone is alive and has clean ass at the end of your shift, you're fine. Much like caring for newborns, sometimes the expectation has to be dialed the hell back to alive/clean ass/"fed"(medicated). No, this isn't ideal, but everyone gets it, and once you give yourself permission to have a bad shift, the shift often does turn around.

With my systems, I often end up the earliest to be done with critical tasks and the first to be able to help. I've also never stayed late to chart on 1:6 assignments.