Controlled Drug Discrepancy on a Night Shift
At 2200 on a 36-bed subdivisional hospital ward, the RN in charge begins the controlled-drug count with a second RN. The register records eight ampoules of pethidine 50 mg; the locked tray contains six. The second RN, a senior colleague with 15 years’ service and a personal friend, says she gave two doses to a postoperative patient but signed for only one. The patient’s medication chart shows one written order and one administration signature. She asks the in-charge nurse not to escalate the matter and offers to ‘correct the book in the morning.’ The nurse manager is off-site and the on-call medical officer is in theatre. Facility policy requires a two-person witness for controlled drugs and an incident report within 24 hours. The in-charge nurse must decide what to do next while the ward is still busy and two other patients are awaiting analgesia.
1. What immediate actions should the RN take to protect patients and preserve the integrity of the controlled-drug record?
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Immediate priorities are patient safety, preservation of the drug record and containment of risk. The RN should not alter the register or allow the colleague to do so. She should recount the tray with a different second witness, secure the remaining ampoules in the locked cupboard, and record the discrepancy exactly as found. She should check the postoperative patient’s chart, observation chart and pain score, and assess the patient for oversedation or respiratory depression, because two unrecorded doses may have been given. She should inform the on-call medical officer and the nurse manager according to policy, and complete an incident report. The colleague should be removed from controlled-drug handling for the rest of the shift pending investigation, without a public accusation. A factual note should be made in the progress notes: time of count, expected and actual quantities, who was present, what was said, and who was notified. If the colleague appears impaired, the RN should ensure she is not left alone with patients and escalate immediately. The aim is not to prove guilt at the bedside but to prevent further patient harm and preserve evidence.
2. How should the RN respond to the request to ‘correct the book,’ and what professional, ethical and legal obligations are engaged?
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The request to ‘correct the book in the morning’ must be refused. A controlled-drug register is a legal record; backdating, altering or making a false entry to match the stock is falsification, even if the intention is to protect a colleague. The RN’s professional obligations include honesty, patient safety, accountability and reporting concerns through the proper channel. The nurse should tell the colleague clearly that she cannot amend the record and that the discrepancy must be reported under facility policy. She should offer support-for example, suggesting the colleague contact the nurse manager or employee assistance-without promising confidentiality that would conceal a patient-safety issue. If a patient received an unrecorded dose, the prescriber must review the patient and open disclosure should be considered if harm occurred. The matter should be documented and escalated to the nurse manager and, if required by Fiji Nursing Council standards or facility policy, to the relevant regulatory or disciplinary authority. Confidentiality applies to the investigation, not secrecy about the discrepancy.
3. What should be included in the incident report and progress notes, and what should be avoided?
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The incident report should be factual and time-specific: date, shift, ward, names of staff present, the expected count (eight ampoules), the actual count (six), the patient identifiers and chart findings, the colleague’s statement, actions taken, persons notified and the time of notification. It should state that the register was not altered and that the remaining stock was secured. Progress notes should use objective language, for example ‘At 2205, controlled-drug count discrepancy identified: register 8, tray 6. Second witness RN X present. On-call MO notified at 2215.’ Avoid opinions such as ‘she stole it’, speculation about motive, blame, or words like ‘probably’. Do not write retrospective entries without labelling them as late entries with the actual time and reason. Do not record confidential health information about the colleague unless relevant to fitness for duty. The report should trigger a formal investigation, a patient review and a review of the witness policy; the RN should keep a copy according to policy and follow up that the report was received.