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SAFETY
CLEVER THIEVES
Swiping Demerol From the Narcotics Cabinet
I
have a crafty nurse to thank for my job as the medication safety officer here at Lehigh Valley Hospital in Allentown, Pa. About 8 years
ago, this nurse began stealing Demerol to feed her own drug habit.
She'd punch in her 4-digit code to open the locked narcotics cabinet,
cut a few tablets out of the unit dose containers and replace them with
other tablets. Because the plastic coverings on the packages were
amber, it was hard to see that she was replacing yellow pills with white
ones.
To conceal her tampering, the nurse taped the Demerol packages
together in strips of 10 so, she claimed, they'd be easier to count.
She got away with this for 4 months. Eventually, though, somebody
noticed that the packages were tampered with and that patients
who received bogus pills were still complaining of pain.
— Leroy Kromis, PharmD
who abuse. That's where you need a drug accountability system that
goes along with the locking cart, one that provides a set of checks and
balances to protect their contents against theft, unmonitored use and
tampering. Some carts even include a separately securable drawer or
section that lets providers lock down their morphine, fentanyl and
other controlled substances at all times. But just because a cart has a
lock doesn't mean it's effective against diversion. This calls to mind the
case of the hospital's chief of anesthesiology who was undermedicating his patients during surgery and taking the rest for himself.
Be sure to select a cart that's easy to lock and unlock, and doesn't
disrupt your workflow. Make it easy to do the right thing. It's a motto
that I use. Your system is only as good as users' ability or willingness
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O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E | A U G U S T 2013