The Count That Does Not Match
On a Tuesday morning, the pharmacist-in-charge at a busy Nashua pharmacy performs the biennial controlled-substance inventory. The count of oxycodone 15 mg tablets is 18 fewer than the perpetual record; fentanyl 25 mcg/hr patches are 6 fewer than the record. The pharmacy uses an automated dispensing cabinet that technicians can access with their own fingerprints. A technician who recently transferred from another store had access to the cabinet and worked the previous weekend. The security camera in the vault has been offline for nine days. The pharmacist-in-charge also finds a prescription for 90 oxycodone 30 mg tablets presented yesterday by a new patient; the prescriber's DEA number checks out, but the signature looks like a stamp. The pharmacy has not yet notified DEA or the Board. The owner asks whether to wait until the end of the month to see if the count 'evens out' and whether to confront the technician alone. The pharmacy is still dispensing from the same stock.
1. What are the reporting obligations and timing for the missing oxycodone and fentanyl?
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The pharmacy should not wait until the end of the month. Missing Schedule II drugs, especially fentanyl patches, are a serious loss. Federal DEA rules require a registrant to notify the DEA field office in writing within one business day of discovering a theft or significant loss, using DEA Form 106. A loss of 18 oxycodone tablets and 6 fentanyl patches from a pharmacy's stock is likely to be treated as significant, and the pharmacy should not decide on its own to wait for a possible paperwork explanation. The pharmacist-in-charge should also notify the New Hampshire Board of Pharmacy promptly under its reporting requirements and should contact local police if theft is suspected. The report should state what is known and what is still under investigation, not speculate about the culprit. Waiting or 'evening out' the count can itself become a recordkeeping violation and aggravate discipline.
2. How should the pharmacy investigate and secure the remaining stock?
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First, secure the remaining controlled substances: change cabinet access codes, suspend the involved technician's access pending investigation, and consider a full audit of all Schedule II-V stock. Second, preserve records: dispensing history, perpetual inventory entries, returns, waste records, purchase invoices, fingerprint access logs, and camera status. Third, reconstruct the period since the last accurate count, looking for unrecorded dispenses, partial fills, transfers, returns, and waste. Fourth, interview staff separately and objectively; do not confront the technician alone or in a way that could become a dispute about coercion. Fifth, document the investigation and corrective actions. The owner's suggestion to confront the technician alone is poor practice because it risks loss of evidence and escalation. The pharmacist-in-charge should involve the appropriate corporate or legal resource and keep the Board and DEA reports consistent with the internal findings.
3. What should be done about the suspicious oxycodone 30 mg prescription?
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The pharmacist should not dispense it until the prescription is verified. A correct DEA number does not prove the prescription is authentic; forged prescriptions often use a real DEA number. The pharmacist should call the prescriber using a number independently obtained, not the number printed on the suspicious prescription, and ask whether the prescriber issued a 90-tablet oxycodone 30 mg prescription for this patient. The pharmacist should also check the PMP for overlapping prescriptions and patient history. If the prescription is forged, the pharmacy should retain it, document the circumstances, and contact local police and possibly the DEA. If it was already dispensed, the pharmacist should document that fact and include it in the investigation. Confronting the patient is not required and may be unsafe; the priority is to avoid dispensing a forged controlled substance and to preserve evidence.