Record Discrepancy in a Controlled Drug Log
You are closing out the controlled-substance log at a small-animal practice. The log shows 10 mL of a Schedule II opioid dispensed from a 20 mL vial on Monday, 10 mL dispensed Tuesday, and the vial should be empty. On Wednesday the vial still contains roughly 4 mL. The Monday entry is initialed by a technician who was on vacation that day; the Tuesday entry has no witness signature. A locum veterinarian worked both days. When you ask the technician whose initials appear, they say the locum 'probably' signed for them because they were away. The practice has no written policy on controlled-drug reconciliation, and the log is kept in an unlocked drawer in the treatment area.
1. What discrepancies and control failures are present, and what should you do with the physical evidence?
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Discrepancies and failures:
- Quantity mismatch - 20 mL recorded as dispensed from a 20 mL vial, but ~4 mL remains. Unexplained volume must be reconciled, not assumed to be measurement error.
- Falsified or improper signature - initials attributed to an absent technician indicate someone signed on their behalf, which is a record-integrity problem with regulatory weight.
- Missing witness signature on the Tuesday entry.
- Unsecured storage - controlled drugs in an unlocked drawer violate basic control expectations.
- No reconciliation policy - no defined schedule or procedure for counts.
Handling the physical evidence:
- Do not discard, top off, or 'correct' the vial. Secure it, label it clearly as quarantined/pending review, and store it in the locked controlled-drug cabinet.
- Perform and document a witnessed physical count of all controlled substances now.
- Preserve the original log pages; do not alter them. Make copies for the investigation.
- Record the date, time, who was present, and the observed volume.
Chain of custody and preservation matter more than resolving the cause on the spot.
2. Outline the escalation and corrective-action steps, distinguishing what you can do yourself from what must go to others.
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Within your authority (do now):
- Secure the vial and the log; conduct a witnessed count.
- Document observations factually and neutrally, without accusing anyone.
- Notify the practice manager or veterinarian-in-charge immediately.
Must go to others:
- Practice owner/manager and DEA registrant: A suspected loss or theft of a controlled substance and a record discrepancy generally trigger reporting obligations; the registrant decides and handles required notifications. Do not make that call alone, but ensure it is raised promptly.
- The locum and the absent technician: The manager should obtain statements; do not interrogate colleagues yourself.
- Formal investigation: Determine whether the volume is explained by an unrecorded waste/return, a dispensing error, or diversion.
Corrective actions to recommend:
- Written controlled-drug policy covering access, double-signature for removal and waste, and reconciliation frequency (e.g., each shift and a periodic full count).
- Locked, access-limited storage.
- Retraining on signing rules: never sign for another person.
- Audit of prior log entries for similar patterns.
Separate the roles: your job is to detect, secure, and report - not to adjudicate.