A Count That Did Not Match

In practice

At the end of the day, a medical assistant and a nurse perform the controlled-substance count that the practice's policy requires. The cabinet is locked, and both of them have their own access. The count for one medication is one unit short of the record. The medical assistant does not suggest recounting until it comes out right, and she does not assume a recording slip. They recount carefully and get the same result. Then they check the day's administration records against the stock. One administration was recorded, but the wasted portion of a partly used dose was not witnessed and documented as the procedure requires. They report the discrepancy to the supervisor and the provider at once, as the policy directs, and document exactly what they found. The supervisor follows the practice's investigation process. That includes determining whether the situation amounts to a theft or significant loss requiring a report to the drug enforcement agency. Afterward, the practice reviews the wasting procedure with all staff.