Hi I am a pharmacist. I had some issues at my hospital with nurses using the flowsheets method (by passing the MAR, patient scanning and bag scanning) to POST document all the narcotic drips like ketamine, ativan, versed, fentanyl, precedex, and propofol . Has any other hospital pharmacists ESPECIALLY WITH EPIC seen this? There was an article written in Pharmacy Practice News volume 48 number 2 February 2021 "Drug Diversion: yet another pandemic challenge" . Drug diversion: yet another pandemic challenge - Issuu
Epic Flowsheets method provides avenue for drug diversion
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precedex and propofol are narcotics?
I jest, but do people actually go through the MAR to analyze if the amount given actually matches up to what was sent? We obviously track the amount sent and RN's have to go through all the documentation/signing, but I could easily see a RN charting something and lowering actual rate and pocketing the rest - would take a little work, but not impossible - but I am not sure how documenting on the flowchart vs the MAR would make a difference in this situation?
I jest, but do people actually go through the MAR to analyze if the amount given actually matches up to what was sent? We obviously track the amount sent and RN's have to go through all the documentation/signing, but I could easily see a RN charting something and lowering actual rate and pocketing the rest - would take a little work, but not impossible - but I am not sure how documenting on the flowchart vs the MAR would make a difference in this situation?
Dear Dred Pirate. You are correct sadly propofol (Michael's milk ) is not controlled and neither is precedex but both should be as both are abused. To think MJ might have been moon walking with a pole and propofol! Right so I have never been a ICU trained pharmacist, so I assumed this was a role they should/might do in regards to your actual amount given is amount sent. I worked multiple hospitals but only seem to notice this irregularity frequently at one and only once at another. I am trying to figure some logistics out. BACK GROUND I have a hospital with no protocol for dual sign off on narcotic drips (and NON-controlled precedex & propofol)and also NO shift change requirement sign off . If the nurses IN EPIC uses the flowsheet method of documentation and BYPASS scanning of patient label and medication label. These dosages and adjustments did not cross to the MAR on integrated alaris pump technology either. It is quite simple to get to the MAR you scan wrist ban label and medication label and if you are logged in ; bam patient's MAR. The flowsheets also are not the MAR medication administration record which is the LEGAL record of all drugs given in a hospital. If you transfer a patient to another hospital you PRINT THE MAR not the FLOWSHEETS. I believe it may have to do with the EPIC build or its a glitch? I am asking to find out. The nurses showed me how to do it and it is HOW you POST DOCUMENT rate changes. So they can post a 8/21 1900 rate change (action time) or new bag start for example and if you clicked into the entry on the MAR it would show the documented event (recorded time) was 8/22 @ 1900 . It is similar to how OR can add back times of forgotten administrations. Plus the timing of the replacement bag requests were egregiously early like when tolerating ventilation weaning.
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Although for most recent machines that connect to Epic or Cerner with the APIs, that doesn't happen easily as the flow rate is controlled by Central.
I would second that paperwork methods are rarely used. Most nurses can't do Benford's Law correctly to fake it to avoid detection by the order check systems. It is simply easier to document correctly then divert. If someone is correctly applying Benford's Law, all you need to do is to figure out which nurses have the most pain meds per patient capita and from time to time, stick a camera on them. I hope most hospitals are putting their cabinets in restricted areas (doesn't necessarily have to be behind an access door, just not open floor) with a camera option if needed.
No lock boxes or CADDs at this place either.
And those in question requested drips 40 hours early based on rate of drip and bag size/concentration. Flowsheets is an area in epic not paper (but agree nursing does not use paper anymore) that is easily editable and does not capture all the information like the MAR.
