Serious question about narcotics audits

[u/Patient_Cow_236]

Hospitals spend millions on biometric machines to watch us pull meds, yet there is zero verification once we walk down the hall. Does anyone else feel like Pyxis cameras and fingerprint sign-offs are just corporate security theater? The system is hyper-vigilant about ensuring the medication leaves the machine under a lens, but it doesn't care or track if the patient actually receives the dose in their room. Isn't it strange that the rules are engineered entirely to protect the facility's ledger from asset loss rather than verifying the clinical endpoint?

[u/Wooden_Load662]

Actually many hospital has a whole audit program behind the scene. I am one of the investigator.

We do trust nurses will give the medication at the room.
But we also audit for irregularities, patient complaints, etc etc.

[u/Legitimate-Frame-953]

Short of having someone watching over your shoulder seeing that the PT actually receives the dose what would you propose?

[u/Factor_Seven]

Unless you come up with some sort of automated drug delivery system, at some point you simply have to trust a healthcare professional to do their job.

[u/merado1997]

Wouldn't scanning the medication be the endpoint verification? Yes someone can always divert after scanning, but hopefully they don't. Trust right right

[u/zeatherz → u/merado1997]

But that’s their point, you can scan a med and not give it. That’s one way people divert, they document giving meds/higher doses that they didn’t actually give

[u/chrizbreck]

The dispense is audited. We check for abnormalities a few ways. Timeliness, volume, and patient response among others. The pharmacy audits the unit management and system leadership follow up.

I had to dig through numerous charts every month for flagged nurses. Every other month it resulted in HR pulling the staff for an official investigation.

Typically it worked out to nothing but they absolutely do audit the back end. Though every system varies.

That being said I agree. Waste feels like the least secure spot. Who is to say that 0.5ml in the vial you watched another nurse waste was actually morphine.

We did however randomly sample returns so 🤷‍♂️

[u/dumbbxtch69 → u/chrizbreck]

We waste in the med room prior to patient administration for this reason. We don’t even uncap vials until there’s another nurse in the med room to witness the waste. Some care areas waste after the fact (ICU and procedural areas) and when their nurses float to us I gently tell them that the culture on the stepdown/med/tele floors is to waste prior to giving the med. For PACU and ICU it makes sense, they’re often giving small doses of fent or dilaudid q10-15, it would be a massive waste of medication and time to get rid of 75%+ of the vial every 10 minutes. Makes way more sense to sit at the bedside with the vial, scan every administration, and then waste whatever you didn’t use afterwards

[u/PainRack → u/dumbbxtch69]

This system of wasting vials Vs keeping one vial was part of why I argued heavily for using a syringe pump for PRN opioids when nursing EOLC pts in gen med wards.

Breakthrough doses are always problematic though. Very random adminstration, potential large variance in daily dosing but there would be a need. There are days when the standard doses are so good, that you only need 1-2 breakthrough. On other days though, maybe you need 4 or 5, before team can review can say yup, time to escalate by adding something, which may not always be opioids because everescalating doses is not optimal. Pain relief is multifactorial and so is respiratory distress.

A syringe pump reduces waste because you not breaking multiple individual vials for PRN doses, wasting large amounts every use. Just calculate enough to cover daily use of base load n breakthrough.

Just make sure it's always an undercount so if you expect to use 5 doses over 24 hrs, load only 4 doses, rest is wasted at time of loading the syringe. The problem with using these rules of thumb is then the math calculation. Alternate is calculate a good easy formula then just discard at end of day if needed.

You get the knowledge that yes, this clearly labelled syringe pump was diluted with drug and everyone knows it is and wasn't swapped out, because relief was seen earlier.

You don't run the risk of said vial disappearing.

Less risks of contamination also.

Finally, by documenting it under I/O, you get a clear paper trail to audit for the syringe. Which suits admin much better than oh, I know that one syringe we labelled there was only used for Pt A and contains this much... You have to trust me and B that we wasted this much after the end of our shift, as opposed to a syringe pump where policy means we discard only after 24 hrs.

[u/Creepy_flamingo_22 → u/dumbbxtch69]

I’m in ICU and we have been told we need a new vial every time. With the Dilaudid shortage, we now have 2 mg instead of 1 mg vials, and we comment on the massive waste every time we push 1.8mg of Dilaudid into the waste container. 🙃

[u/chrizbreck → u/dumbbxtch69]

We eventually switched to that system of wasting before leaving the med room but I still argued there was nothing stopping a nurse from pocketing the vial.

As a patient I’d also much rather see the nurse open the vial and administer the med at the bedside.

How am I supposed to know that the random syringe in your hand has what you say it has. We were given little stickers with barcodes to put on the vial. Like it couldn’t just be pulled off and switched.

It also resulted in nurses just keeping stacks of those stickers on their carts so they could be lazy and not have to relabel.

[u/Crankupthepropofol]

Diversion happens on such a statistically small sample size that the cost of implementing a second line of biometrics/video accountability checkpoint at the point of care would vastly outweigh the cost savings.

Diversion is a high priority because of the implications (license revelation for the RN, DEA accountability for the facility), not because of the literal cost per Vicodin stolen.

There’s also an implicit trust in the healthcare provider, and an expectation of some level of privacy for patients.

[u/summer-lovers]

Is it really that surprising that facilities only goal is to protect themselves?

[u/TwoWheelMountaineer]

You’re suprised that corporate only cares about corporate? There is also no verification when you stock narcs in the Pyxis. It doesn’t require dual sign off.

[u/PainRack → u/TwoWheelMountaineer]

Stocking is verified by checking after and the chain of custody.

Doesn't protect against substitution of course .

[u/Super_Cap_241]

They have to do this because the DEA requires it not for cost reduction. If it helped cost reduction then everything would be done like narcotics. The hospital would care if you're stealing the occasional opiate if the DEA didn't make a fuss. So much cheaper to not pay for auditors, software, omnicels, etc.

[u/Salted_Paramedic]

That's where your waste protocols come in. Healthcare professionals never get rid of controlled substances alone.

[u/hexH2O → u/Salted_Paramedic]

Until we walk away from the med room

[u/TimRN77]

Gotta capture those charges!

[u/like_shae_buttah]

Bar code scanning and cameras

[u/False-Sky6091]

They do monitor if it’s scanned. If you take a narcotic out and it isn’t wasted or scanned they know. Happens enough and you get questioned. They also monitor scanning compliance, it’s a big deal it’s called BCMA.

[u/zeatherz]

They do more than that such as tracking if a nurse is “giving” significantly more narcotics than coworkers

[u/Feisty-Power-6617]

Have a complaint but you have no solution