UNRAVELING AUTOMATED DISPENSING SYSTEM REPORTS

UNRAVELING AUTOMATED DISPENSING SYSTEM REPORTSTraining for Investigators

Presented by

Lucas Overmire, MSc

Co-owner and Partner

©2021 Diversion Specialists, LLC. All Rights Reserved.

TOPIC AREAS


Background information

Available Options for ADM reports and what to ask for

How to read and interpret ADM reports

Case Studies

BACKGROUND INFORMATION

UNRAVELING

AUTOMATED

DISPENSING

SYSTEM

REPORTS


PRIMARY DRUGS OF CHOICE & COVID IMPACT


Injectables:

• Hydromorphone• Morphine• Fentanyl• Propofol

Pills and liquids:

• Hydrocodone• Oxycodone

Patches:

• Fentanyl

OTHER DRUGS OF CHOICE


Benzodiazepines (lorazepam, alprazolam, clonazepam)

Ondansetron, promethazine, diphenhydramine, acetaminophen

Cyclobenzaprine, ketorolac, gabapentin

Anesthesia gases, naloxone

SIGNS OF DIVERSION


Removal of medication; no administration

Removal of medication when not needed

Removal for discharged patient

Removal of duplicate dose

Removal of/diversion from fentanyl patches

Removal of medication without order

Diversion from waste

Frequent breaking of containers for injectables

Removal under sign-on of colleague

Removal of oral and injectable opioid at the same time

Tampering

RX DIVERSION INDEX

R x Au d i t o r

©2021 DIVERSION SPECIALISTS, LLC. ALL RIGHTS RESERVED.

Basic Sta t i s t ica l Compar ison



ANOMALOUS USAGE

Pa n d o r a A n a ly t i c s


Basic Sta t i s t ica l Compar ison


Report Criteria

Group: Site/Area

Group

Sub-Group: Med

Sub-Group

Group Members

Members


Population: Total number of users

who have removed a specific med in

the specified timeframe

Mean: Average quantity of the

med removed by a user in the

specified timeframe

Upper Inner Fence:

Slightly above the75th

percentile

Upper Outer Fence:

Between the 75th and 95th

percentile

Standard Deviation:A measure of how far

a data point is from the mean. A high standard

deviation means the data points are more

spread out.

AVAILABLE OPTIONS FOR

ADM REPORTS AND WHAT TO ASK

FOR

UNRAVELING

AUTOMATED

DISPENSING

SYSTEM

REPORTS


STEPS FOR MAKING REPORT REQUESTS


Know some basics for your request (ADM system, report criteria)Know

Ask for transaction reportsAskReview the ADM report, then ask for corresponding EHR reports for specific patients (to include medication administrations, pain score documentation, etc.)

Review

Manually compare the ADM reports to the EHR reports –make notes on your findings Compare

ALL DEVICE EVENTS

P y x i s E S


ADM Transact ion Repor t

PYXISREPORTS RECOMMENDED CRITERIA

*Transaction data beyond 90

days can be sent from BD

Carefusion Knowledge Portal

report


Date Range Whatever is needed, up to ~90 days*

Devices All

Med Classes All

Meds All

Transaction Types

All

Users <select user of interest>

PYXIS TRANSACTION REPORT FORMATS

*Can be manipulated, but may not

look as clean as CSV format

^Easy to send if documentation

noted in XLS; harder if report

printed and notes made by hand


CSV PDF XLS

Manipulate after Export

Yes No Yes*

Requires advanced Excel skills

Yes No No

Prints nicely Yes, with manipulation

Yes Yes

Easy to Send to Others

Yes (attach to email)

No (scan required)

Maybe^

TRANSACTIONS BY USER

O m n i c e l l X T



OMNICELLRECOMMENDED CRITERIA

Note: you may want to request

a “Report Abbreviation

Key”(for Omnicell) with any

reports requested, which will

define fields that may otherwise

be unclear


Date Range Whatever is needed, up to at least 7 years

Omni All

Item Control Levels

All

Transaction Types

All


OMNICELLTRANSACTION REPORT FORMATS


PDF XLS


No Yes


No Yes

Prints nicely Yes Yes, with manipulation


No (scan required)


STATION EVENTS (BY USER)

A c u d o s e - R x



ACUDOSERECOMMENDED CRITERIA


Date Range Specify date range

Station All

From DEA Code (to) DEA Code

Rx (to) 5

Transaction Types

All


ACUDOSETRANSACTION REPORT FORMATS


PDF XLS


No Yes


No Yes

Prints nicely Yes Yes, with manipulation


No (scan required)


OTHER COMMON TRANSACTION REPORTS


Knowledge Portal (Pyxis only)

• All Transaction Activity Detail –CSV, PDF, or XLS (similar to Pyxis reports)

Pandora Analytics

• Activity Report –PDF or CSV

RxAuditor

• Transactions Details – XLS only

OTHER TIPS FOR REQUESTING REPORTS


Ask for all control levels (not just CS)

If receiving a PDF, ask that data be sorted by patient, then by date

HOW TO READ AND INTERPRET

ADM REPORTS

UNRAVELING

AUTOMATED

DISPENSING

SYSTEM

REPORTS


ALL DEVICE EVENTS

P y x i s E S




Filter Criteria: Control Levels 2-5Transaction Types

User of Interest

Note: Several Columns Deleted

for ease of viewing BEFORE export

Duck, Donald

ICU

ICU

ICU

ICU

ICU

ICU

ICU

ICU

ICU

ICU

ICU

GOOSE, MOTHERGOOSE, MOTHER

GOOSE, MOTHERGOOSE, MOTHERHEADLESS, HORSEMANHEADLESS, HORSEMANCRANE, ICABOD

CRANE, ICABODCRANE, ICABOD

MUDDLEFOOT, HONKER

MERMAID, LITTLE

This is what you receive back from the hospitalADM Transact ion Repor t : Pyxis Transact ions (PDF)


Filter Criteria: Control Levels 2-5Transaction Types

User of Interest

Several Columns Deleted for ease of viewing BEFORE

export

This is what you receive back from the hospitalADM Transact ion Repor t : Pyxis Transact ions (XLS)


This is what you receive back from the hospitalADM Transact ion Repor t : Pyxis Transact ions (CSV)


Manually Added Columns: administration amount, administration

time, comments, amount missing

Several Columns Deleted for ease of viewing; turned on

auto filter

Compare the Pyxis report to the EHR report(s)Manual ly Merged ADM/EHR data : Pyxis Transact ions (CSV)


NOTE ON OMITTING COLUMNS (PYXIS ONLY)Uncheck everything except those below

to fit on standard paper for printing (if using PDF or XLS):

TRANSACTIONS BY USER

O m n i c e l l X T




Duck, Donald

GOOSE, MOTHER

HEADLESS, HORSEMAN

CRANE, ICABOD

SMITH, JOHN

MUDDLEFOOT, HONKER

MERMAID, LITTLE

Mouse, Minnie

HEADLESS, HORSEMAN

Duck, Donald

OCICU – Intensive Care Unit

OCMS – Medical/Surgical Unit

Filter Criteria: Date

Control Levels Transaction

TypesUser of Interest

This is what you receive back from the hospitalADM Transact ion Repor t : Omnice l l Transact ions (PDF)


This is what you receive back from the hospitalADM Transact ion Repor t : Omnice l l Transact ions (XLS)


Several Columns Deleted for ease of

viewing; turned on auto filter

Manually Added Columns: order info,

admin time, pain score, pain score time,

comments

Compare the Omnicell report to the EHR report(s)

Manual ly Merged ADM/EHR data : OC Transact ions (XLS)

STATION EVENTS (BY USER)

A c u d o s e - R x




Filter Criteria: Date

Control Levels Transaction

TypesUser of Interest

Goose, Mother

Goose, Mother

Mouse, Minnie

Mouse, Minnie

Duck, Donald DD1234

This is what you receive back from the hospitalADM Transact ion Repor t : Acudose Transact ions (PDF)


This is what you receive back from the hospitalADM Transact ion Repor t : Acudose Transact ions (XLS)


Several Columns Deleted for ease of viewing; turned on auto filter

Manually Added Columns: administration amount, administration time, pain score, order info, comments, amount missing

Compare the Acudose report to the EHR report(s)

Manual ly Merged ADM/EHR data : Acudose Transact ions (XLS)

CASE STUDIESUNRAVELING

AUTOMATED

DISPENSING

SYSTEM

REPORTS


EXAMPLE A


Adminis t ra t ion Before Pul l


A1


Simpson,

LOR7.5/32

HYDROcodone/Acetaminophen 7.5mg/325mg

2 tabs q6h prn

pain score 8; follow

Bart POSTOP 5T (Lortab / Norco) Tablet(s) 3 Remove 2 Tablet(s) 3028897886 1/22/2019 16:15 pain 7-10 2 tabs 1619 up pain score 5 Simpson, Bart

POSTOP

LOR7.5/32 5T

HYDROcodone/Acetaminophen 7.5mg/325mg (Lortab / Norco) Tablet(s)

3

Remove

2

Tablet(s)

3028999856

1/22/2019 12:48

2 tabs q6h prn

pain score 8; follow

pain 7-10 2 tabs 1252 up pain score 3 Simpson, Bart

POSTOP

O4I

Ondansetron (Zofran) 4 mg/2 mL Injection

0

Remove

1

Injection

3028999856

1/22/2019 12:48

Simpson, Bart

POSTOP

O4I


0

Remove

1

Injection

3029024787

1/22/2019 11:56

Simpson, Bart

POSTOP

TC3

Acetaminophen/Codeine 300mg/30mg (#3) (Tylenol w/ Codeine) Tablet(s)

3

Remove

1

Tablet(s)

3029002171

1/22/2019 10:06

Simpson, Bart

POSTOP

T325

Acetaminophen (Tylenol) 325 mg Tablet(s)

0

Remove

3

Tablet(s)

3028746331

1/22/2019 9:06

Simpson, Bart

POSTOP

GAB300C

Gabapentin (Neurontin) 300 mg Capsule

0

Remove

2

Capsule

3028746331

1/22/2019 9:06

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028998080

1/22/2019 7:46

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3029038340

1/18/2019 6:30

Simpson, Bart

POSTOP

GAB300C


0

Remove

2

Capsule

3029038340

1/18/2019 6:30

Simpson,

HYD1SY HYDROmorphone (Dilaudid) 1 mg/1 mL Injection HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL

HYD0.5SY Injection KETI Ketamine 200 mg/20 mL Injection MOR4VL Morphine (Vial) 4 mg/1 mL Injection

1 Injection

1 Injection

190 mg

2 mg

0.5mg q5m to 3mg 0.5MG, 1620, Bart POSTOP 2 Remove 3028893299 1/17/2019 16:23 total 0.5MG 1645 before pull Simpson, 0.5mg q5m to 3mg Bart POSTOP 2 Remove 3028893299 1/17/2019 16:17 total 0.5mg 1610 before pull Simpson, Bart POSTOP 3 Waste 3029036948 1/17/2019 15:58 DELAYED WASTE Simpson, Bart POSTOP 2 Waste 3029036948 1/17/2019 15:55 DELAYED WASTE Simpson, Bart

POSTOP

ACE1000I

Acetaminophen (Ofirmev) 1000 mg/100 mL Injection

0

Remove

1

Injection

3029036948

1/17/2019 13:48

1GM IV X1

1GM

1345

Simpson, Bart

POSTOP

KET30SY

Ketorolac (Toradol) 30 mg/1 mL Injection

0

Remove

1

Injection

3029036948

1/17/2019 13:48

VO 30MG OT

30MG

1350

Simpson, Bart

POSTOP

MOR4VL

Morphine (Vial) 4 mg/1 mL Injection

2

Remove

1

Injection

3029036948

1/17/2019 13:48

2MG Q5M TO

20MG TOTAL 2MG 1352 2MG

A2


Simpson,

0.5MG Q10M TO

0.5MG,

1320,

Bart POSTOP HYD1SY HYDROmorphone (Dilaudid) 1 mg/1 mL Injection 2 Remove 1 Injection 3028717795 1/17/2019 13:16 4MG TOTAL 0.5MG 1330 before pull BEFORE PULL; PULLED AT SAME Simpson, 0.5MG Q10M TO 0.5MG, 1250, TIME FOR ANOTHER Bart POSTOP HYD1SY HYDROmorphone (Dilaudid) 1 mg/1 mL Injection 2 Remove 1 Injection 3028717795 1/17/2019 12:56 4MG TOTAL 0.5MG 1305 PT TOO Simpson, 2MG Q5M TO 1250, Bart POSTOP MOR4VL Morphine (Vial) 4 mg/1 mL Injection 2 Remove 1 Injection 3029036948 1/17/2019 12:56 20MG TOTAL 2MG, 2MG 1315 BEFORE PULL Simpson, 0.5MG Q10M TO 0.5MG, 1225, Bart POSTOP HYD1SY HYDROmorphone (Dilaudid) 1 mg/1 mL Injection 2 Remove 1 Injection 3028717795 1/17/2019 12:30 4MG TOTAL 0.5MG 1235 BEFORE PULL ORDER TOTAL Simpson, 0.5MG Q10M TO 0.5MG, 1200, LOOKS WRITTEN Bart POSTOP HYD1SY HYDROmorphone (Dilaudid) 1 mg/1 mL Injection 2 Remove 1 Injection 3028717795 1/17/2019 12:00 4MG TOTAL 0.5MG 1210 OVER Simpson, Bart

POSTOP

MOR2SY

Morphine 2 mg/1 mL Injection

2 Remove

1 Injection

3029036948

1/17/2019 11:47

NO ADMIN

2MG

Simpson, Bart

POSTOP

MOR4VL


2

Remove

1

Injection

3029036948

1/17/2019 11:41

2MG Q5M TO

1138,

20MG TOTAL 2MG,2MG 1145

Simpson, Bart

POSTOP

MOR4VL


2

Remove

1

Injection

3029036948

1/17/2019 11:01

2MG Q5M TO

1100,

20MG TOTAL 2MG,2MG 1130

Simpson, Bart

POSTOP

KETI

Ketamine 200 mg/20 mL Injection

3

Remove

1

Injection

3029036948

1/17/2019 10:30

10MG Q10M TO

50MG TOTAL 10MG 1032

Simpson, Bart

POSTOP

MOR2SY

Morphine 2 mg/1 mL Injection

2

Remove

1

Injection

3029036948

1/17/2019 10:17

2MG Q5M TO

20MG TOTAL 2MG, 2MG 1020

Simpson, Bart

POSTOP

MOR4VL


2

Remove

1

Injection

3029036948

1/17/2019 10:00

2MG Q5M TO

1002,

20MG TOTAL 2MG, 2MG 1010

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028968208

1/16/2019 6:47

Simpson, Bart

POSTOP

LOR7.5/32 5T


3

Remove

1

Tablet(s)

3028918583

1/15/2019 13:29

1 TAB Q4PRN PAIN

4-6 1 TAB 1335

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028947459

1/15/2019 12:03

Simpson, Bart

POSTOP

GAB300C


0

Remove

1

Capsule

3028947459

1/15/2019 12:03

Simpson, Bart

POSTOP

LOR7.5/32 5T


3

Remove

1

Tablet(s)

3029068230

1/15/19 10:54

1 TAB Q4PRN PAIN 4-6 1 TAB 1108

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3029030453

1/15/2019 10:31

A3


Simpson, Bart POSTOP T325 Acetaminophen (Tylenol) 325 mg Tablet(s) 0 Remove 3 Tablet(s) 3028994642 1/15/2019 9:02 Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028918583

1/15/2019 8:10

Simpson, Bart

POSTOP

GAB300C


0

Remove

2

Capsule

3028918583

1/15/2019 8:09

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028911000

1/15/2019 6:45

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028898181

1/15/2019 6:23

Simpson, Bart

POSTOP

HYD1SY

HYDROmorphone (Dilaudid) 1 mg/1 mL Injection

2 Remove

1 Injection

3029073560

1/14/2019 21:44

NO ADMIN

1MG

HYD0.5SY

HYD1SY

O4I

HYD1SY

O4I

HYD1SY

HYD1SY

HYD1SY HYD1SY HYD1SY

HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL Injection HYDROmorphone (Dilaudid) 1 mg/1 mL Injection






HYDROmorphone (Dilaudid) 1 mg/1 mL Injection HYDROmorphone (Dilaudid) 1 mg/1 mL Injection HYDROmorphone (Dilaudid) 1 mg/1 mL Injection

1 Injection

1 Injection

1 Injection

1 Injection

1 Injection

1 Injection

1 Injection

0.5 mg

1 Injection

1 Injection

ALL PREVIOUS

DOSES BY ANOTHER RN; SIGNATURE Simpson, ORDER NOT CLEAR LOOKS DIFFERENT Bart POSTOP 2 Remove 3028940561 1/14/2019 21:05 (CROSSED OUT) 0.5MG 2054 THIS TIME Simpson, 0.5mg q5m to 2mg 0.5MG, 2005, Bart POSTOP 2 Remove 3029073560 1/14/2019 20:15 total 0.5MG 2020 WAY BEFORE PULL Simpson, Bart POSTOP 0 Remove 3029073560 1/14/2019 20:15 4MG X1 4MG 2000 BEFORE PULL BEFORE PULL; SOMETIMES WRITES Simpson, 0.5mg q5m to 2mg 0.5MG, 1945, MILITARY TIME, Bart POSTOP 2 Remove 3029073560 1/14/2019 19:49 total 0.5MG 1955 SOMETIMES NOT Simpson, Bart POSTOP 0 Remove 3028919672 1/10/2019 16:17 4mg OT 4MG 1610 BEFORE PULL BEFORE PULL; SCRIBBLED Simpson, 0.5mg q5m to 2mg 0.5MG, 1615, OVER/HARD TO Bart POSTOP 2 Remove 3028919672 1/10/2019 16:17 total 0.5MG 1625 READ Simpson, 0.5mg q5m to 2mg 0.5MG, 1540, Bart POSTOP 2 Remove 3028919672 1/10/2019 15:48 total 0.5MG 1555 before pull Simpson, Bart POSTOP 2 Waste 3028787483 1/10/2019 14:22 DELAYED WASTE Simpson, 0.5MG Q10M TO 0.5MG, 1405, Bart POSTOP 2 Remove 3028890972 1/10/2019 14:11 1MG TOTAL 0.5MG 1420 before pull Simpson, 0.5MG Q10M TO Bart POSTOP 2 Remove 3028787483 1/10/2019 13:03 2MG TOTAL 0.5MG 1300 BEFORE PULL

A4


BEFORE PULL; ALSO

DEMEROL 12.5MG Simpson, 0.5MG Q10M TO 0.5mg, 1225, @ 1200, 1215 (WHO Bart POSTOP HYD1SY HYDROmorphone (Dilaudid) 1 mg/1 mL Injection 2 Remove 1 Injection 3028787483 1/10/2019 12:32 2MG TOTAL 0.5mg 1240 PULLED?) Simpson, Bart

POSTOP

HYD1SY


2 Remove

1 Injection

3028871139

1/10/2019 10:03

0.5mg q5m to 2mg BEFORE PULL; NO total 0.5mg 1000 WASTE 0.5MG

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028931180

1/10/2019 6:30

Simpson, Bart

POSTOP

GAB300C


0

Remove

2

Capsule

3028931180

1/10/2019 6:29

Simpson, Bart

POSTOP

O5T

OxyCODONE 5 mg Tablet(s)

2 Remove

1 Tablet(s)

3028904625

1/9/2019 13:34

5mg q4h prn pain 4-6 5mg 1413 delayed admin; ASC

Simpson, Bart

POSTOP

GAB300C


0

Remove

1

Capsule

3028985848

1/9/2019 13:27

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028858995

1/9/2019 11:13

Simpson, Bart

POSTOP

GAB300C


0

Remove

2

Capsule

3028858995

1/9/2019 11:12

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028904625

1/9/2019 9:24

Simpson, Bart

POSTOP

GAB300C


0

Remove

1

Capsule

3028904625

1/9/2019 9:24

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028812885

1/8/2019 10:16

Simpson, Bart

POSTOP

GAB300C


0

Remove

2

Capsule

3028812885

1/8/2019 10:15

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028856809

1/8/2019 6:40

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028735235

1/8/2019 6:14

Simpson, Bart

POSTOP

GAB300C


0

Remove

1

Capsule

3028735235

1/8/2019 6:14

Simpson, Bart

POSTOP

HYD1SY


2 Waste

0.5 mg

3028739971

1/7/2019 16:26

DELAYED WASTE

Simpson, Bart

POSTOP

HYD1SY


2

Remove

1

Injection

3028739971

1/7/2019 15:38

0.5mg q5m to 3mg

total 0.5MG 1540

A5


Simpson,

0.5mg q5m to 3mg 0.5mg,

1505,

Bart POSTOP HYD1SY HYDROmorphone (Dilaudid) 1 mg/1 mL Injection 2 Remove 1 Injection 3028739971 1/7/2019 15:09 total 0.5mg 1520 BEFORE PULL Simpson, Bart Simpson, Bart

POSTOP

POSTOP

O4I

HYD1SY



0 Remove

2 Remove

1 Injection

1 Injection

3028739971

3028674806

1/7/2019 15:09

1/7/2019 13:21

NO ORDER

0.5mg q10m to NO WASTE - 2mg total 0.5MG 1330 COMPAZINE 1320 0.5MG

Simpson, Bart Simpson, Bart

POSTOP POSTOP

HYD1SY O4I

HYDROmorphone (Dilaudid) 1 mg/1 mL Injection Ondansetron (Zofran) 4 mg/2 mL Injection

2 Remove

0 Remove

1 Injection

1 Injection

3028674806

3028674806

1/7/2019 13:06

1/7/2019 13:06

0.5mg q10m to 0.5mg, 1305, 2mg total 0.5mg 1315 BEFORE PULL; SAME OT 4MG 1305 TIME AS DILAUDID

Simpson, Bart

POSTOP

ACE1000I

Acetaminophen (Ofirmev) 1000 mg/100 mL Injection

0

Remove

1

Injection

3028674806

1/7/2019 12:55

1gm IV AFTER 1245 1GM 1255

Simpson, Bart

POSTOP

HYD1SY


2

Remove

1

Injection

3028671497

1/7/2019 12:11

0.5MG Q10M TO 1MG TOTAL

NO PACU RECORD, BUT ANOTHER RN SEEMS TO BE CARING FOR THE PATIENT

ANOTHER RN (C FLOWERS) ALSO PULLED 1MG; NO WASTE FROM Simpson, 0.5MG Q10M TO 0.5mg, 1147, EITHER--WAS IT 0.5MG- Bart POSTOP HYD1SY HYDROmorphone (Dilaudid) 1 mg/1 mL Injection 2 Remove 1 Injection 3028946097 1/7/2019 12:03 1MG TOTAL 0.5mg 1157 HANDED OFF? 1MG Simpson, Bart Simpson, Bart Simpson, Bart Simpson, Bart

POSTOP POSTOP

POSTOP

POSTOP

HYD1SY HYD1SY

HYD1SY

HYD1SY

HYDROmorphone (Dilaudid) 1 mg/1 mL Injection HYDROmorphone (Dilaudid) 1 mg/1 mL Injection



2 Waste

2 Remove

2 Remove

2 Remove

0.5 mg

1 Injection

1 Injection

1 Injection

3028730723

3028730723

3028730723

3028970774

1/7/2019 11:48

1/7/2019 10:55

1/7/2019 10:41

1/7/2019 10:24

WASTE--another RN pulled and admin 0.5mg 1109 0.5 WAS WASTED; 0.5mg q5m to 2mg another RN pulled total 0.5mg 1100 and admin 0.5mg 0.5mg q5m to 2mg 0.5mg, 1035, total 0.5mg 1045 before pull 0.5mg q10m to 0.5mg, 1024, by another RN (C 1mg total 0.5mg 1033 FLOWERS);

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028622862

1/7/2019 6:50

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028907354

1/7/2019 6:14

Simpson, Bart

POSTOP

GAB300C


0

Remove

2

Capsule

3028907354

1/7/2019 6:13

A6


Simpson,

MORPF10

Bart POSTOP I Morphine PF 10 mg/10 mL Injection 2 Waste 9 mg 3027796162 1/4/2019 10:50 WASTE Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028954802

1/4/2019 10:45

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028839722

1/4/2019 8:26

Simpson, Bart

POSTOP

GAB300C


0

Remove

1

Capsule

3028839722

1/4/2019 8:25

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028785495

1/4/2019 7:53

Simpson, Bart

POSTOP

GAB300C


0

Remove

2

Capsule

3028785495

1/4/2019 7:53

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028902942

1/4/2019 6:46

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028898843

1/4/2019 6:20

Simpson, Bart

POSTOP

GAB300C


0

Remove

2

Capsule

3028898843

1/4/2019 6:19

Simpson, Bart

POSTOP

T325


0

Remove

3

Tablet(s)

3028929515

1/3/2019 6:31

Simpson, Bart

POSTOP

LOR5/325 T

HYDROcodone/Acetaminophen 5mg/325mg (Lortab / Norco) Tablet(s)

2

Remove

1

Tablet(s)

3028693210

1/2/2019 12:17

OT

1 TAB

1220

Simpson, Bart

POSTOP

HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL HYD0.5SY Injection

2 Remove

1 Injection

3028693210

1/2/2019 11:54

0.5mg q10m to 2mg total NO ADMIN 0.5MG

Simpson, Bart

POSTOP

HYD1SY HYDROmorphone (Dilaudid) 1 mg/1 mL Injection

2 Remove

1 Injection

3028693210

1/2/2019 11:37

SCRIBBLED 0.5mg q10m to 0.5mg, 1140, OVER/HARD TO 2mg total 0.5mg 1155 READ TIME

Simpson, Bart

POSTOP

O4I


0

Remove

1

Injection

3028693210

1/2/2019 11:37

4mg OT

4mg

1140

Simpson, Bart

POSTOP

HYD1SY


2

Remove

1

Injection

3028948762

1/2/2019 11:17

0.5mg q10m to

0.5mg,

1120,

2mg total 0.5mg 1131

Simpson, Bart

POSTOP

HYD1SY HYDROmorphone (Dilaudid) 1 mg/1 mL Injection

2 Remove

1 Injection

3028948762

1/2/2019 10:51

0.5mg q10m to

0.5mg,

1045,

2mg total 0.5mg 1105 before pull

A7


Factor Count

Total number of CS transactions by this RN in one month (Withdrawal, Return, Waste)

111

Delayed waste 4

Administration before pull 20

Unaccounted for (withdrawal, return, waste, administration don’t add up)

7

EXAMPLE ASUMMARY

Adminis t ra t ion Before Pul l

A8

EXAMPLE B


Tr y i t :I ’ve a l ready matched the ADM repor t to the EHR repor t .

Mark any problem areas on the fo l lowing repor t pages. Then, determine what the main method of d ivers ion i s here and document on the summar y page.

Time: 10 minutes


UserName Device MedDescription TransactionType Quantit QtyUOM ID TransactionDateT Admin Pain Comments Missing Brown, Charlie PACU HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL (0.5 mL) Inj Remove 1 Inj 2101797013 5/2/2018 12:53 12:58 6 Brown, Charlie PACU Keys-Epid PCA (CADD Solis) (Keys-Epid PCA (CADD Solis)) 1 EA Misc Remove 1 Misc 2101797732 5/2/2018 12:54 Brown, Charlie PACU HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL (0.5 mL) Inj Waste 0.1 mg 2101797013 5/2/2018 13:12 Waste Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101797013 5/2/2018 13:13 13:20 6 Handed off waste Brown, Charlie PACU morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj Remove 1 Inj 2101824486 5/2/2018 14:30 handed off Brown, Charlie PACU KEYS-ALARIS PCA SYRINGE PUMP Device Remove 1 Device 2101824486 5/2/2018 14:31 Brown, Charlie PACU HYDROmorphone (Dilaudid) 30 mg/30 mL (30 mL) Inj Remove 1 Inj 2101824486 5/2/2018 14:31 handed off Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 2101826945 5/2/2018 15:33 N/A No order Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 2101826945 5/2/2018 15:33 15:40 6 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101826945 5/2/2018 15:33 15:40 5 Brown, Charlie PACU acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 2101826945 5/2/2018 15:34 N/A No order Brown, Charlie PACU ketorolac (Toradol) 30 mg/1 mL (1 mL) Inj Remove 1 Inj 2101814198 5/2/2018 16:09 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 50 mcg 2101826945 5/2/2018 16:10 Waste Brown, Charlie PACU nitroGLYCerin 2% (Nitro-Bid) 1 in Oint Remove 1 Oint 2101814198 5/2/2018 16:25 Brown, Charlie

PACU

morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj

Remove

1

Inj

2101814198 5/2/2018 16:26

2 mg wasted by another waste RN 2 mg

Brown, Charlie PACU propofol (Diprivan) 1000 mg/100 mL (100 mL) Inj Remove 1 Inj 3041130828 5/2/2018 17:31 Handed off Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 3 Tab 3041147384 5/2/2018 19:14 19:16 7 Handed off Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 3041147384 5/2/2018 19:15 19:16 7 Handed off Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101772784 5/3/2018 11:10 11:15 8 Handed off Brown, Charlie PACU ondansetron (Zofran) 4 mg/2 mL (2 mL) Inj Remove 1 Inj 2101772784 5/3/2018 11:14 11:17 Handed off Brown, Charlie PACU albuterol-ipratropium (Duoneb) (3 mL) Soln Remove 1 Soln 2101822761 5/3/2018 11:38 Brown, Charlie PACU acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 2101823751 5/3/2018 14:57 N/A No order Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 3 Tab 2101823751 5/3/2018 14:57 15:00 5 Brown, Charlie PACU morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj Remove 1 Inj 2101823751 5/3/2018 14:58 15:00 5 Brown, Charlie PACU morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj Waste 2 mg 2101823751 5/3/2018 15:22 Waste Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 3041155106 5/3/2018 16:03 N/A No order Brown, Charlie PACU prochlorperazine (Compazine) 10 mg/2 mL (2 mL) Inj Remove 1 Inj 3041155106 5/3/2018 16:03 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 3041155106 5/3/2018 16:03 16:06 8 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 3041155106 5/3/2018 16:04 16:06 8 Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 3041155106 5/3/2018 16:04 N/A No order Brown, Charlie PACU acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 3041155106 5/3/2018 16:04 N/A No order Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 50 mcg 3041155106 5/3/2018 17:33 Waste Brown, Charlie PACU acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 3041158597 5/3/2018 20:23 N/A No order Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 3041158597 5/3/2018 20:23 N/A No order Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 3041158597 5/3/2018 20:23 20:23 9 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 3041158597 5/3/2018 20:23 20:26 7 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 25 mcg 2101815567 5/3/2018 20:24 Waste Handed off waste Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 50 mcg 2101824536 5/3/2018 20:25 Waste Handed off waste Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Waste 0.4 mg 2101824536 5/3/2018 20:25 Waste Handed off waste Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 2101792790 5/7/2018 10:52 10:55 6 Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 2101792790 5/7/2018 10:52 N/A No order Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101792790 5/7/2018 10:53 10:55 6 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 75 mcg 2101792790 5/7/2018 11:22 Waste Brown, Charlie PACU metoclopramide (Reglan) 10 mg/2 mL (2 mL) Inj Remove 1 Inj 2101803316 5/7/2018 16:19 Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 2101820971 5/7/2018 16:30 16:31 6 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101820971 5/7/2018 16:30 16:34 6 Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Waste 0.5 mg 2101820971 5/7/2018 17:20 Waste Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101820732 5/7/2018 17:38 Handed off Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 2101810881 5/9/2018 9:48 N/A No order Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101810881 5/9/2018 9:48 10:08 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101810881 5/9/2018 9:48 !0:08 Brown, Charlie PACU acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 2101810881 5/9/2018 9:49 N/A No order Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101826481 5/9/2018 12:05 12:30 7

B1


UserName Device MedDescription TransactionType Quantit QtyUOM ID TransactionDateT Admin Pain Comments Missing Brown, Charlie PACU ondansetron (Zofran) 4 mg/2 mL (2 mL) Inj Remove 1 Inj 2101826481 5/9/2018 12:05 12:08 Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 2101826481 5/9/2018 12:05 12:30 8 Brown, Charlie PACU acetaminophen (Ofirmev) 1000 mg/100 mL (100 mL) Inj Remove 1 Inj 2101826481 5/9/2018 12:39 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101828651 5/9/2018 16:39 16:55 5 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101828651 5/9/2018 16:39 16:55 5 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 75 mcg 2101828651 5/9/2018 17:37 Waste Brown, Charlie

PACU

oxyCODONE IR (Roxicodone) 5 mg Tab

Remove

2

Tab

2101815427

5/10/2018 10:38

Gave hydromorphone as well pulled by another RN 10:43 7 at 10:16

Brown, Charlie PACU acetaminophen-oxy COD ONE (percocet) 325 mg-5 mg (Percocet 5/325) Tab Remove 2 Tab 2101817134 5/10/2018 12:20 12:24 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101824742 5/10/2018 16:18 handed off Brown, Charlie PACU ondansetron (Zofran) 4 mg/2 mL (2 mL) Inj Remove 1 Inj 2101824742 5/10/2018 16:19 handed off Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101745079 5/15/2018 11:40 handed off Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 50 mcg 2101745079 5/15/2018 12:54 Waste handed off waste Brown, Charlie PACU acetaminophen (Ofirmev) 1000 mg/100 mL (100 mL) Inj Remove 1 Inj 2101822738 5/15/2018 13:48 Brown, Charlie PACU ketorolac (Toradol) 30 mg/1 mL (1 mL) Inj Remove 1 Inj 2101822738 5/15/2018 14:02 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101822738 5/15/2018 14:25 14:28 10 Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 2101822738 5/15/2018 14:26 14:28 10 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 2101823009 5/15/2018 15:48 15:56 8 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101823009 5/15/2018 15:48 15:57 7 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 50 mcg 2101823009 5/15/2018 16:28 Waste Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Return to bin 1 Inj 2101841001 5/15/2018 16:28 RETURN Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 3041196761 5/15/2018 19:13 19:17 5 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 3041196761 5/15/2018 19:13 N/A Returned see below Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Return to bin 1 Inj 3041196761 5/15/2018 19:21 RETURN Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 3041196761 5/15/2018 19:24 N/A No order Brown, Charlie PACU acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 3041196761 5/15/2018 19:24 N/A No order Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101831036 5/16/2018 10:24 10:26 5 Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 2101831036 5/16/2018 10:24 N/A No order Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 2101831036 5/16/2018 10:24 10:27 5 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Return to bin 1 Inj 2101833933 5/16/2018 10:25 RETURN Handoff at return Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Waste 0.5 mg 2101831036 5/16/2018 11:05 Waste Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101841696 5/16/2018 11:46 11:28 2 One time order Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101844039 5/18/2018 11:31 11:34 5 Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 2101844039 5/18/2018 11:32 N/A No order Brown, Charlie PACU acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 2101844039 5/18/2018 11:32 N/A No order Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101756035 5/18/2018 12:19 12:21 8 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 2101756035 5/18/2018 12:38 12:49 8 Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 2101756035 5/18/2018 12:39 12:46 8 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 75 mcg 2101756035 5/18/2018 14:00 Waste Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101847883 5/18/2018 16:53 handed off Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101847883 5/18/2018 17:13 handed off Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 3041209614 5/18/2018 17:22 17:38 8 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 3041209614 5/18/2018 17:22 N/A Returned see below Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 2101847883 5/18/2018 17:26 handed off Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 3041209614 5/18/2018 17:36 17:38 7 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Return to bin 1 Inj 3041209614 5/18/2018 17:36 RETURN Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Waste 0.5 mg 3041209614 5/18/2018 18:17 Waste Brown, Charlie PACU morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj Remove 1 Inj 3041208681 5/18/2018 18:32 handed off Brown, Charlie PACU morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj Remove 1 Inj 3041208681 5/18/2018 18:43 handed off Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove Cancelled 0 Inj 3041217260 5/21/2018 12:27 CX Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove Cancelled 0 Inj 3041215868 5/21/2018 12:28 CX Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 3 Tab 2101844781 5/21/2018 12:40 12:41 6 One time order Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 2101792717 5/21/2018 16:02 handed off

B2


UserName Device MedDescription TransactionType Quantit QtyUOM ID TransactionDateT Admin Pain Comments Missing Brown, Charlie PACU ketorolac (Toradol) 30 mg/1 mL (1 mL) Inj Remove 1 Inj 2101792717 5/21/2018 17:05 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101841159 5/23/2018 10:36 10:39 7 Brown, Charlie PACU acetaminophen (Ofirmev) 1000 mg/100 mL (100 mL) Inj Remove 1 Inj 2101841159 5/23/2018 10:36 Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Waste 0.5 mg 2101841159 5/23/2018 11:32 Waste handed off Brown, Charlie PACU albuterol-ipratropium (Duoneb) (3 mL) Soln Remove 1 Soln 2101832646 5/23/2018 11:39 Brown, Charlie PACU albuterol-ipratropium (Duoneb) (3 mL) Soln Remove 1 Soln 2101837413 5/23/2018 12:11 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101837413 5/23/2018 12:28 12:52 8 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101837413 5/23/2018 12:50 12:52 7 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 3041210869 5/23/2018 15:22 15:33 9 Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 3041210869 5/23/2018 15:22 15:24 9 Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 3041210869 5/23/2018 15:43 N/A No order Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 3041210869 5/23/2018 15:43 15:47 8 Brown, Charlie PACU acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 3041210869 5/23/2018 15:44 N/A No order Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Waste 0.5 mg 3041210869 5/23/2018 16:48 Waste Brown, Charlie PACU hydrALAZINE (HydrALAZINE) 20 mg/1 mL (1 mL) Inj Remove 1 Inj 2101846984 5/29/2018 9:55 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101846984 5/29/2018 9:55 9:58 8 Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 2101846984 5/29/2018 9:55 N/A No order Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Remove 1 Inj 2101846984 5/29/2018 9:56 9:58 8 Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Waste 0.5 mg 2101846984 5/29/2018 10:51 Waste Brown, Charlie PACU ondansetron (Zofran) 4 mg/2 mL (2 mL) Inj Remove 1 Inj 2101854541 5/29/2018 11:00 N/A Cx Surgery? Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 2101831895 5/29/2018 11:51 12:03 8 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101831895 5/29/2018 11:51 12:03 8 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101831895 5/29/2018 12:13 12:23 7 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 50 mcg 2101831895 5/29/2018 12:49 Waste Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 3041240924 5/29/2018 13:11 handed off Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 3041240924 5/29/2018 13:25 handed off Brown, Charlie PACU insulin lispro (HumaLOG) 300 units Inj Remove 1 Inj 3041243274 5/29/2018 14:51 Brown, Charlie PACU acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 2101849210 5/30/2018 9:59 10:05 6 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 2101849210 5/30/2018 10:00 N/A No order Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101856744 5/30/2018 11:33 12:00 4 Brown, Charlie PACU morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj Remove 1 Inj 2101856744 5/30/2018 11:33 11:35 4 Brown, Charlie PACU SUFentanil (Sufenta) 50 mcg/1 mL (1 mL) Inj Waste 10 mcg 2101844989 5/30/2018 11:34 Brown, Charlie PACU morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj Waste 2 mg 2101856744 5/30/2018 12:12 Waste Brown, Charlie PACU HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj Waste 0.5 mg 2101837132 5/30/2018 16:21 Waste handed off Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 3041244777 5/30/2018 17:47 N/A No order Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Waste 10 mg 3041244777 5/30/2018 18:22 Waste Wasted complete dose Brown, Charlie PACU morphine (Morphine) 150 mg/30 mL (30 mL) Inj Remove 1 Inj 2101818058 6/6/2018 19:21 19:32 Brown, Charlie PACU KEYS-ALARIS PCA SYRINGE PUMP Device Remove 1 Device 2101818058 6/6/2018 19:22 Brown, Charlie PACU ondansetron (Zofran) 4 mg/2 mL (2 mL) Inj Remove 1 Inj 2101865463 6/7/2018 10:28 10:33 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Remove 1 Inj 2101845879 6/13/2018 9:08 handed off Brown, Charlie PACU hydrALAZINE (HydrALAZINE) 20 mg/1 mL (1 mL) Inj Remove 1 Inj 2101845879 6/13/2018 10:20 Brown, Charlie PACU KEYS-ALARIS PCA SYRINGE PUMP Device Remove 1 Device 3041297742 6/13/2018 12:53 Brown, Charlie PACU HYDROmorphone (Dilaudid) 30 mg/30 mL (30 mL) Inj Remove 1 Inj 3041297742 6/13/2018 12:53 N/A Returned see below Brown, Charlie PACU HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL (0.5 mL) Inj Return to bin 2 Inj 3041297742 6/13/2018 13:11 RETURN Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 50 mcg 2101846018 6/13/2018 17:38 Waste handed off waste Brown, Charlie PACU KEYS-ALARIS PCA SYRINGE PUMP Device Remove 1 Device 2101848501 6/13/2018 17:48 Brown, Charlie PACU HYDROmorphone (Dilaudid) 30 mg/30 mL (30 mL) Inj Remove 1 Inj 2101848501 6/13/2018 17:48 18:58 Brown, Charlie PACU fentaNYL (Sublimaze) 100 mcg/2 mL (2 mL) Inj Waste 50 mcg 2101848501 6/13/2018 19:27 Waste handed off Brown, Charlie PACU acetaminophen (Tylenol Extra Strength) 500 mg Tab Remove Cancelled 0 Tab 2101863344 6/21/2018 11:54 N/A No order Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 2101863344 6/21/2018 11:54 11:58 6 Brown, Charlie PACU HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL (0.5 mL) Inj Remove 1 Inj 2101863344 6/21/2018 11:54 11:58 6 Brown, Charlie PACU acetaminophen (Ofirmev) 1000 mg/100 mL (100 mL) Inj Remove 1 Inj 2101863344 6/21/2018 11:54 11:57

B3


UserName Device MedDescription TransactionType Quantit QtyUOM ID TransactionDateT Admin Pain Comments Missing Brown, Charlie

PACU

acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 2101863344 6/21/2018 11:55 N/A No order at time of pull. Order at 12:26 for fever or pain 3 or less

Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 2101835888 6/21/2018 13:58 14:02 6 Brown, Charlie PACU ondansetron (Zofran) 4 mg/2 mL (2 mL) Inj Remove 1 Inj 2101835888 6/21/2018 13:58 14:01 Brown, Charlie PACU HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL (0.5 mL) Inj Remove 1 Inj 2101835888 6/21/2018 13:58 N/A Returned see below Brown, Charlie PACU HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL (0.5 mL) Inj Return to bin 1 Inj 2101835888 6/21/2018 16:45 RETURN Brown, Charlie PACU HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL (0.5 mL) Inj Remove 1 Inj 2101866982 6/22/2018 9:29 None Dose not documented 0.5 mg Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 1 Tab 2101850986 6/22/2018 11:35 11:35 4 Brown, Charlie

PACU

propofol (Diprivan) 1000 mg/100 mL (100 mL) Inj Remove 1 Inj 2101837900 6/22/2018 11:48 None Only prop given was by anesthesia between 7 and 8 am

Brown, Charlie PACU HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL (0.5 mL) Inj Remove 1 Inj 2101837900 6/22/2018 13:16 14:18 Brown, Charlie PACU oxyCODONE IR (Roxicodone) 5 mg Tab Remove 2 Tab 3041330576 6/22/2018 14:21 14:34 6 Brown, Charlie PACU HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL (0.5 mL) Inj Remove 1 Inj 3041330576 6/22/2018 14:21 14:35 7 Brown, Charlie PACU acetaminophen (Tylenol) 325 mg Tab Remove Cancelled 0 Tab 3041330576 6/22/2018 14:21 N/A No order Brown, Charlie PACU HYDROmorphone (Dilaudid) 0.5 mg/0.5 mL (0.5 mL) Inj Remove 1 Inj 2101846299 6/22/2018 14:56 handed off

B4


Method of Diversion Cancelled Transactions (Substitution)

Number of related instances

18 cancelled transactions18 times “access” without order

Other comments Only 3 “unaccounted for” medications

EXAMPLE BSUMMARY

B5

EXAMPLE C


Adminis t ra t ion Issues


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments hung 2115 admin 1mg 2130 - not wasted until next day no admin no admin - wasted entire dose next day admin 2200 by another RN admin by another RN 2200 no admin - wasted later admin 2200 (documented 0108) no admin; admin 2300 by another RN - also removed from Pyxis by Rn who admin admin 2200 documented 0111 admin 2300 (documented 0055) by another RN admin 0200 (documented 0106) pain score 6 admin 0200 (documented 0106) no admin - wasted later no admin - wasted later admin 0600 (documented 0647) pain score 4 no admin no admin no admin no admin no admin no admin no admin delayed waste wasted entire dose wasted entire dose wasted entire dose wasted entire dose wasted entire dose delayed waste delayed waste

Jasmine, Princess HOSPICE morphine (Morphine) 150 mg/30 mL (30 mL) Inj 2 Remove 1 Inj 3040731865 1/4/2018 21:03 Jasmine, Princess

HOSPICE

LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj

4

Remove

1

Inj

3040731865

1/4/2018 21:03

Jasmine, Princess Jasmine, Princess

HOSPICE HOSPICE

morphine (Morphine) 150 mg/30 mL (30 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj

2

4

Remove Remove

1

1

Inj Inj

3040731360

3040731360

1/4/2018 21:04

1/4/2018 21:28 Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess

HOSPICE HOSPICE HOSPICE HOSPICE

morphine ER (MS Contin) 60 mg Tab ER LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc

2 4 2

2

Remove Remove Remove Remove

1 1 1

1

Tab ER Conc Conc Conc

3040632964 3040632964 3040708053

3040722849

1/4/2018 22:14 1/4/2018 22:15 1/4/2018 22:21

1/4/2018 22:22

Jasmine, Princess

HOSPICE

HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj

2

Remove

2

Inj

3040722849

1/4/2018 22:28

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE



LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc

morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C

LORazepam (Ativan) 1 mg Tab morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj

2

4

2

4 2 2

2

Remove

Remove

Remove

Remove Remove Remove Remove

1

1

1

1 1 1

2

Inj

Conc

Conc

Tab Conc Conc Inj

3040728911

3040653069

3040731832

3040731832 3040708053 3040708053

3040726451

1/4/2018 23:31

1/4/2018 23:36

1/5/2018 1:01

1/5/2018 1:01 1/5/2018 2:14 1/5/2018 6:04

1/5/2018 6:07

Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess

HOSPICE HOSPICE HOSPICE HOSPICE HOSPICE HOSPICE HOSPICE

morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C LORazepam (Ativan) 1 mg Tab morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj

2 4 2 4 2 2 2

Remove Remove Remove Remove Remove Override Remove

1 1 1 1 1 1 1

Conc Tab Conc Conc Conc Inj Inj

3040731832 3040731832 3040731683 3040731683 3040731683 3040731832 3040728911

1/5/2018 6:10 1/5/2018 6:10 1/5/2018 6:46 1/5/2018 7:23 1/5/2018 7:23 1/5/2018 7:26 1/5/2018 7:42



LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc

4 2 2 2

Waste Waste Waste Waste

1 5 5 5

mg mg mg mg

3040731865 3040708053 3040708053 3040708053

1/5/2018 9:21 1/5/2018 9:21 1/5/2018 9:22 1/5/2018 9:22


HOSPICE HOSPICE

LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj

4 4

Waste Waste

1 1

mg mg

3040731360 3040731360

1/5/2018 9:22 1/5/2018 9:22


HOSPICE HOSPICE

methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc

2 4

Waste Waste

8 0.5

mg mg

3040722849 3040632964

1/5/2018 9:23 1/5/2018 9:23

C1


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments No admin - discrep -2 after this admin 2200 (documented 2252) no pain score admin 2300 (documented 0002) cancelled - still documented 1mg admin 2230 @ 0759 admin 0200 (documented 0234) admin 0200 (documented 0234) pain score 6 cancelled - still documented admin 0600 @ 0746 admin 0600 (documented 0746) pain score 6 admin 0600 (documented 0758) no pain score delayed waste delayed waste admin 2200 (documented 2233) no pain score admin 2330 (documented 0338) admin 0200 (documented 0345) no pain score admin 0600 (documented 0610) no pain score) admin 0607 pain score 4 waste delayed waste admin 2mg 1000 (documented 0929) - wheres the waste?

Jasmine, Princess

HOSPICE


2

Remove

2

Conc

3040708053

1/5/2018 19:26

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE


methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc

2

2

Remove

Remove

1

1

Inj

Conc

3040731683

3040735734

1/5/2018 22:32

1/5/2018 22:58

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



4

4

Remove Ca

Remove

0

1

Inj

Inj

3040731683

3040734976

1/6/2018 0:31

1/6/2018 1:17

Jasmine, Princess

HOSPICE


2

Remove

1

Inj

3040734976

1/6/2018 1:40

Jasmine, Princess HOSPICE morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C 2 Remove 4 Conc 3040735734 1/6/2018 5:38 Jasmine, Princess

HOSPICE


4

Remove Ca

0

Inj

3040734976

1/6/2018 6:08

Jasmine, Princess

HOSPICE


2

Remove

1

Inj

3040734976

1/6/2018 6:09

Jasmine, Princess

HOSPICE


2

Remove

1

Inj

3040731683

1/6/2018 6:33


HOSPICE HOSPICE

methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj

2 4

Waste Waste

2.5 1

mg mg

3040735734 3040734976

1/6/2018 6:43 1/6/2018 6:44

Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040735734 1/6/2018 21:06 Jasmine, Princess HOSPICE methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040735734 1/6/2018 21:07

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE

HOSPICE





2

4

2

2

Remove

Remove

Remove

Remove

1

1

1

1

Inj

Inj

Inj

Inj

3040731683

3040738209

3040731683

3040731683

1/6/2018 22:06

1/6/2018 23:18

1/7/2018 1:42

1/7/2018 5:22

Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040735734 1/7/2018 5:26 Jasmine, Princess HOSPICE methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040735734 1/7/2018 5:26 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040724027 1/7/2018 5:51 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Waste 15 mg 3040724027 1/7/2018 6:22 Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Waste 1 mg 3040738209 1/7/2018 6:22 Jasmine, Princess HOSPICE methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc 2 Waste 2.5 mg 3040735734 1/7/2018 6:23 Jasmine, Princess HOSPICE methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc 2 Waste 2.5 mg 3040735734 1/7/2018 6:23 Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040722849

1/9/2018 9:01

C2


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments 2mg admin 1000 (documented 0929) pain score 5 admin 1000 pain score 2 (order for pain 4-10) 1mg admin 1000 (documented 1041) - where's the waste? admin 1000 (documented 1039) no pain score admin 1200 no admin 2mg admin 1315 (documented 1348) pain score 6 admin 1400 (documented 1347) no pain score admin 1400 (documented 1328) admin 1400 (documented 1349) no pain score admin 1400 (documented 1346) pain score 2 (order for 4-10) admin 1400 (documented 1348) pain score 4 admin 1500 (documented 1535) no pain score admin 1525 (documented 1535) no pain score no admin admin 1701 no pain score 1mg admin 1701 - wheres the waste? no admin no admin

Jasmine, Princess HOSPICE methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040722849 1/9/2018 9:01

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

2

Remove

Remove

2

1

Inj

Conc

3040722849

3040653069

1/9/2018 9:01

1/9/2018 9:33 Jasmine, Princess

HOSPICE


2

Remove

1

Inj

3040728051

1/9/2018 9:34 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040728051 1/9/2018 9:34 Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040730701

1/9/2018 10:24

Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040653069 1/9/2018 11:27 Jasmine, Princess HOSPICE morphine IR (Morphine IR) 15 mg Tab 2 Remove 1 Tab 3040632964 1/9/2018 11:59

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

2

Remove

Remove

2

1

Inj

Inj

3040722849

3040728051

1/9/2018 13:07

1/9/2018 13:17 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040728051 1/9/2018 13:17

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE

ALPRAZolam (Xanax) 0.25 mg Tab



4

2

2

Remove

Remove

Remove

1

1

1

Tab

Conc

Conc

3040730701

3040730701

3040653069

1/9/2018 13:25

1/9/2018 13:25

1/9/2018 13:26

Jasmine, Princess

HOSPICE

morphine ER (MS Contin) 15 mg Tab ER

2 Remove

3

Tab ER

3040632964

1/9/2018 13:27

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE


morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc

2

2

Remove

Remove

1

1

Tab ER

Conc

3040730701

3040730701

1/9/2018 15:10

1/9/2018 15:10

Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040728051 1/9/2018 15:56 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040728051 1/9/2018 15:56 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 2 Inj 3040728051 1/9/2018 16:52

Jasmine, Princess

HOSPICE


4

Remove

1

Inj

3040728051

1/9/2018 16:54

Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040728051 1/9/2018 16:54 Jasmine, Princess Jasmine, Princess

HOSPICE HOSPICE

HYDROmorphone (Dilaudid) 2 mg Tab LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc

2 4

Remove Remove

5 1

Tab Conc

3040722849 3040653069

1/9/2018 17:57 1/9/2018 17:58

C3


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments no admin no admin no admin no admin admin 1000 documented 111 no pain score 5mg admin 1000 (documented 1042) - wheres the waste? admin 1000 (documented 1235) no pain score admin 1200 (documented 1232) admin 1233 pain score 4 admin 1400 (documented 2039) admin 1345 (documented 2039) no pain score admin 1400 documented 2038 no pain score no admin no admin waste doesn't match (no admin)

waste doesn't match (no admin) delayed waste delayed waste admin 1015 (documented 1053) no pain score admin 1015 (documented 1053)

admin 1030 documented 1047 admin 1047 pain score 4 (no follow up pain score) admin 1045



morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj HYDROmorphone (Dilaudid) 2 mg Tab morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc

2 2 2 2

Remove Override Remove Remove

1 1 5 1

Conc Inj Tab Conc

3040653069 3040728051 3040722849 3040740460

1/9/2018 17:58 1/9/2018 18:00 1/10/2018 8:12 1/10/2018 9:53

Jasmine, Princess

HOSPICE


2

Remove

2 Inj

3040748265

1/10/2018 9:55

Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040722849

1/10/2018 9:56 Jasmine, Princess HOSPICE methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040722849 1/10/2018 9:56

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

4

Remove

Remove

1

1

Tab ER

Conc

3040730701

3040653069

1/10/2018 10:48

1/10/2018 12:28

Jasmine, Princess HOSPICE morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C 2 Remove 1 Conc 3040653069 1/10/2018 12:28

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE

ALPRAZolam (Xanax) 0.25 mg Tab



4

2

2

Remove

Remove

Remove

1

1

2

Tab

Conc

Inj

3040730701

3040730701

3040748265

1/10/2018 13:43

1/10/2018 13:44

1/10/2018 13:46


HOSPICE HOSPICE

morphine ER (MS Contin) 15 mg Tab ER morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc

2 2

Remove Remove

3 1

Tab ER Conc

3040632964 3040740460

1/10/2018 13:46 1/10/2018 13:47

Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040749347 1/10/2018 15:42 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040749347 1/10/2018 15:42

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

2

Waste

Waste

15

15

mg

mg

3040740460

3040740460

1/10/2018 21:18

1/10/2018 21:18


HOSPICE HOSPICE

morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc

2 2

Waste Waste

10 10

mg mg

3040730701 3040730701

1/10/2018 21:19 1/10/2018 21:19

Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Waste 15 mg 3040749347 1/10/2018 21:20 Jasmine, Princess

Jasmine, Princess

Jasmine, Princess


HOSPICE

HOSPICE

HOSPICE

HOSPICE HOSPICE




morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj

4

2

4

2 4

Remove

Remove

Remove

Remove Remove

1

1

1

1 1

Inj

Inj

Conc

Conc Inj

3040740460

3040740460

3040754701

3040754701 3040745071

1/12/2018 9:47

1/12/2018 9:47

1/12/2018 9:49

1/12/2018 9:49 1/12/2018 9:51

C4


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments admin 1015 (documented 1045) pain score 6; next pain score 2 @ 1045 5mg admin 1000 (documented 1051) - no waste admin 1208 pains core 4 (no follow up pain score) admin 1419 pain score 4 admin 1400 (documented 1419) pain score 6 admin 1800 (documented 1908) pain score 4 admin 1700 (documented 1909) admin 1700 (documented 1909) pain score 6 admin 1800 (documented 1910) pain score 5 admin 1130 (documented 1258) admin 0800 (documented 1103) pain score 6 no admin admin 0900 (documented 1037) pain score 4; next pain score 1037 pain score 2 admin 1000 (documented 1039) pain score 5 5mg admin 1000 (documented 1039) - no waste no admin admin 1130 (documented 1258) 0.5mg admin 1200 admin 1200 (documentated 1253) no pain score admin 1255 pain score 4; no follow up pain score

Jasmine, Princess

HOSPICE


2

Remove

1

Inj

3040745071


HOSPICE


2

Remove

1

Conc

3040737300


HOSPICE


2

Remove

1

Conc

3040754701

1/12/2018 12:04

Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040737300 1/12/2018 13:58 Jasmine, Princess

HOSPICE


2

Remove

1

Inj

3040745071

1/12/2018 13:59

Jasmine, Princess

HOSPICE


2

Remove

1

Inj

3040745071

1/12/2018 17:11

Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040754701 1/12/2018 17:12

Jasmine, Princess HOSPICE morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C 2 Remove 1 Conc 3040754701 1/12/2018 17:12 Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040737300

1/12/2018 17:29

Jasmine, Princess

HOSPICE


4

Remove

1

Inj

3040740460

1/14/2018 7:32

Jasmine, Princess HOSPICE HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040740460 1/14/2018 7:32 Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040754701 1/14/2018 8:44 Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040754701

1/14/2018 8:45

Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040737300 1/14/2018 9:38

Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040737300

1/14/2018 9:38

Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040737300 1/14/2018 9:38 Jasmine, Princess

HOSPICE


2

Remove

1

Inj

3040740460

1/14/2018 11:14


Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040745071 1/14/2018 12:11

Jasmine, Princess HOSPICE morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C 2 Remove 1 Conc 3040754701 1/14/2018 12:16

C5


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments admin 1230 (documented 1256) pain score 4 admin 1230 (documented 1257) no admin no admin--wasted whole dose admin 1800 (documented 1815) no pain score admin 1745 (documented 1818) pain score 6 admin 1745 (documented 1818) delayed waste delayed waste delayed waste delayed waste delayed waste delayed waste delayed waste wasted the whole dose delayed waste delayed waste delayed waste - where did this come from? No corresponding removal admin 0810 no pain score no admin no admin 5mg admin 1000 (documented 1247) admin 1030 (documented 1247) pain score 5 admin 1130 (documented 1208) admin 1424 pain score 4 admin 1425 admin 1800 (documented 1917) admin 1830 (documented 1918) pain score 6

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

4

Remove

Remove

1

1

Conc

Conc

3040737300

3040737300

1/14/2018 12:28

1/14/2018 12:28


HOSPICE HOSPICE

HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj

2

4

Remove Remove

1

1

Inj Inj

3040740460

3040745071

1/14/2018 14:41

1/14/2018 17:12

Jasmine, Princess

HOSPICE


2 Remove

1

Inj

3040745071

1/14/2018 17:12

Jasmine, Princess

HOSPICE


2 Remove

1

Conc

3040737300

1/14/2018 17:29

Jasmine, Princess

HOSPICE


4 Remove

1

Conc

3040737300

1/14/2018 17:30

Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess

HOSPICE HOSPICE HOSPICE HOSPICE HOSPICE HOSPICE

HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc

2 2 4 2 4 4

Waste Waste Waste Waste Waste Waste

0.5 0.5

1 0.5

1 0.5

mg mg mg mg mg mg

3040740460 3040740460 3040740460 3040740460 3040740460 3040754701

1/14/2018 20:18 1/14/2018 20:19 1/14/2018 20:19 1/14/2018 20:19 1/14/2018 20:19 1/14/2018 20:19


HOSPICE HOSPICE


4 4

Waste Waste

1 1

mg mg

3040745071 3040745071

1/14/2018 20:20 1/14/2018 20:20


HOSPICE HOSPICE

LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc

4 2

Waste Waste

1.5 5

mg mg

3040737300 3040737300

1/14/2018 20:21 1/14/2018 20:21

Jasmine, Princess

HOSPICE


2

Waste

5

mg

3040737300

1/14/2018 20:21 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040765525 1/15/2018 8:02 Jasmine, Princess Jasmine, Princess

HOSPICE HOSPICE

morphine (Morphine) 150 mg/30 mL (30 mL) Inj LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc

2 4

Remove Remove

1 1

Inj Conc

3040765525 3040737300

1/15/2018 9:15 1/15/2018 10:05

Jasmine, Princess

HOSPICE


2 Remove

1

Conc

3040737300

1/15/2018 10:05

Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040754701

1/15/2018 10:23

Jasmine, Princess Jasmine, Princess Jasmine, Princess

HOSPICE HOSPICE HOSPICE

LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc

4 2 4

Remove Remove Remove

1 1 1

Inj Conc Conc

3040765525 3040737300 3040737300

1/15/2018 11:01 1/15/2018 13:21 1/15/2018 13:21

Jasmine, Princess

HOSPICE


4 Remove

1

Conc

3040754701

1/15/2018 18:22

Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040754701

1/15/2018 18:23

C6


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments admin 1838 by another RN pain score 5 admin 1838 by another RN waste delayed waste delayed waste admin 0945 (documented 0948) pain score 4 cancelled admin 0900 (documented 0941) admin 0900 (documented 0940) no pain score 5mg admin 1015 (documented 1112) delayed waste delayed waste 5mg admin 1224 - no pain score - no waste admin 1224 admin 1245 (documented 1349) pain score 4 admin 1349 (documented 1350) no admin documented 1708 admin 1800 (documented 1847) pain score 4 admin 0900 (documented 1015) pain score 6 0.5mg admin 0930 (documented 1024) - no waste no admin wasted the whole dose; documented as admin admin 1830 (documented 1925) hung 1134

Jasmine, Princess

HOSPICE


2 Remove

1

Conc

3040737300

1/15/2018 18:24

Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040737300 1/15/2018 18:24 Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Waste 0.5 mg 3040754701 1/15/2018 18:25 Jasmine, Princess HOSPICE methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc 2 Waste 5 mg 3040737300 1/15/2018 18:26 Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Waste 1 mg 3040765525 1/15/2018 18:26

Jasmine, Princess

HOSPICE


2 Remove

2

Inj

3040737300

1/18/2018 8:27

Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove Ca 0 Inj 3040737300 1/18/2018 8:28

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



4

2

Remove

Remove

1

1

Inj

Inj

3040771614

3040771614

1/18/2018 9:04

1/18/2018 9:04

Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040737300

1/18/2018 10:25


HOSPICE HOSPICE

LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc

4 2

Waste Waste

1 5

mg mg

3040771614 3040737300

1/18/2018 11:48 1/18/2018 11:49


HOSPICE


2 Remove

1

Conc

3040774816

1/18/2018 12:20


Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

2

Remove

Remove

2

2

Inj

Inj

3040737300

3040737300

1/18/2018 12:44

1/18/2018 13:51

Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040737300 1/18/2018 16:44 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 2 Inj 3040737300 1/18/2018 16:45

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE


HYDROmorphone (Dilaudid) 4 mg Tab

2

2

Remove

Remove

1

1

Inj

Tab

3040771614

3040797544

1/18/2018 17:32

1/24/2018 9:07



LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc HYDROmorphone (Dilaudid) 4 mg Tab

4 4

2

Remove Remove Waste

1 1

4

Conc Conc mg

3040765483 3040792537

3040797544

1/24/2018 9:50 1/24/2018 10:43

1/24/2018 10:45


HOSPICE HOSPICE

LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc HYDROmorphone (Dilaudid) 30 mg/30 mL (30 mL) Inj

4 2

Remove Remove

1 1

Conc Inj

3040792537 3040772380

1/24/2018 18:45

1/27/2018 8:44

C7


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments 1mg admin 0915 (documented 1134) - wheres the waste? admin 0900 (documented 1131) pain score 6 1mg admin 1131 - wheres the waste? admin 1000 (documented 1132) admin 1000 (documented 1133) no admin admin 1356 no pain score 1mg admin 1357 - wheres the waste admin 5mg 1830 (documented 2136) - no waste no admin admin 1830 (documented 2155) admin 1000 (documented 1021) pain score 4 admin 0950 (documented 1022) pain score 2 admin 1400 (documented 1752) no pain score admin 1600 (documented 1750) pain score 6 admin 1630 (documented 1752) waste admin 1800 (documented 1752) no pain score admin 1820 pain score 5

Jasmine, Princess

HOSPICE


4

Remove

1

Inj

3040772380

1/27/2018 8:55 Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040772380 1/27/2018 8:55

Jasmine, Princess

HOSPICE


2 Remove

1

Inj

3040800868

1/27/2018 9:13

Jasmine, Princess

HOSPICE


4 Remove Ca

0

Inj

3040800868

1/27/2018 9:14

Jasmine, Princess

HOSPICE


4 Remove

1

Conc

3040765483

1/27/2018 10:08

Jasmine, Princess

HOSPICE


2 Remove

1

Tab ER

3040804282

1/27/2018 10:09

Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040804282 1/27/2018 10:11 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040804282 1/27/2018 10:11 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040805230 1/27/2018 13:05

Jasmine, Princess

HOSPICE


4 Remove

1

Inj

3040805230

1/27/2018 13:06

Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040805230 1/27/2018 13:06 Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040804282

1/27/2018 16:52 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040804282 1/27/2018 16:52 Jasmine, Princess Jasmine, Princess

HOSPICE HOSPICE


2 2

Remove Remove

1 1

Conc Conc

3040765483 3040765483

1/27/2018 17:34 1/27/2018 17:34

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE




4

2

2

Remove

Remove

Remove

1

1

1

Conc

Inj

Inj

3040804282

3040765483

3040823084

1/27/2018 18:20

1/31/2018 9:50

1/31/2018 9:50

Jasmine, Princess

HOSPICE


2 Remove

1

Inj

3040823084

1/31/2018 14:24

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

4

Remove

Remove

1

1

Inj

Inj

3040824397

3040824397

1/31/2018 15:37

1/31/2018 15:47

Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Waste 1 mg 3040824397 1/31/2018 16:54

Jasmine, Princess

HOSPICE


2 Remove

1

Inj

3040823084

1/31/2018 17:35


C8


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments admin 1000 (documented 0947) no pain score no admin no admin no admin

admin 1000 (documented 1040)

admin 1000 (documented 1040) 5mg admin 1000 (documented 1345) admin 1000 (documented 1345) pain score 4 admin 1000 (documented 1332) admin 1030 (documented 1333) pain score 6 no admin admin 1342 no pain score admin 1342 admin 1400 (documented 1344) pain score 8 admin 10mg 1400 (documented 1828) pain score 4 admin 1400 (documented 1343) admin 1400 (documented 1346) pain score 4 no admin no admin admin 10mg 1700 (documented 1829) pain score 4 no admin admin 1800 (documented 1825) pain score 8 admin 1800 (documented 1830) no pain score

Jasmine, Princess

HOSPICE


2 Remove

1 Inj

3040823084

2/1/2018 9:48

Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040824397 2/1/2018 9:55 Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040824397 2/1/2018 9:56 Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040824397 2/1/2018 9:56 Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040839841 2/3/2018 9:56

Jasmine, Princess

HOSPICE


2 Remove

1 Conc

3040815395

2/3/2018 10:42

Jasmine, Princess HOSPICE LORazepam (Ativan) 1 mg Tab 4 Remove 1 Tab 3040815395 2/3/2018 10:42

Jasmine, Princess HOSPICE methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040737300 2/3/2018 10:43


Jasmine, Princess HOSPICE clonazePAM (KlonoPIN) 1 mg Tab 4 Remove 1 Tab 3040824405 2/3/2018 11:13

Jasmine, Princess HOSPICE morphine ER (MS Contin) 15 mg Tab ER 2 Remove 1 Tab ER 3040824405 2/3/2018 11:16 Jasmine, Princess HOSPICE HYDROmorphone (Dilaudid) 4 mg Tab 2 Remove 1 Tab 3040800298 2/3/2018 12:18 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040804621 2/3/2018 12:54 Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040804621 2/3/2018 12:54 Jasmine, Princess

HOSPICE


2 Remove

1

Tab ER

3040800298

2/3/2018 13:49

Jasmine, Princess

HOSPICE


2 Remove

1 Conc

3040824405

2/3/2018 13:49


Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 2 Inj 3040737300 2/3/2018 14:08 Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040838579 2/3/2018 14:24 Jasmine, Princess HOSPICE oxyCODONE Concentrate (Roxicodone Intensol) 5 mg/0.25 m 2 Remove 1 Conc 3040838579 2/3/2018 14:24 Jasmine, Princess

HOSPICE


2

Remove

1

Conc

3040824405

2/3/2018 16:42 Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040824405 2/3/2018 16:42

Jasmine, Princess

HOSPICE


2 Remove

1

Tab

3040800298

2/3/2018 17:47


C9


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments


no admin - wasted entire dose admin 1832 admin 1832 pain score 4 late wasted - wasted entire dose delayed waste delayed waste delayed waste delayed waste delayed waste admin 0800 (documented 0822) pain score 8 admin 0823 no pain score admin 1037 pain score 6 admin 1000 (documented 1039) admin 1000 (documented 1039) admin 1330 (documented 1457) no pain score admin 1456 admin 1400 (Documented 1454) pain score 6 no admin admin 1300 (documented 1453) pain score 6 admin 1400 (documented 1452) pain score 6 - last pain score 5 1400 (documented 1453) no admin admin 1800 (documented 2045) pain score 4 delayed waste admin 1000 admin 1000 pain score 4 admin 1000 (documented 1434) pain score 4

Jasmine, Princess

HOSPICE

LORazepam (Ativan) 1 mg Tab

4

Remove

1

Tab

3040815395

2/3/2018 17:48

Jasmine, Princess

HOSPICE


2 Remove

1

Conc

3040824405

2/3/2018 17:48

Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040838579 2/3/2018 18:19 Jasmine, Princess HOSPICE oxyCODONE Concentrate (Roxicodone Intensol) 5 mg/0.25 m 2 Remove 1 Conc 3040838579 2/3/2018 18:19 Jasmine, Princess

HOSPICE


2 Waste

20

mg

3040824405

2/3/2018 21:33

Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Waste 0.5 mg 3040839841 2/3/2018 21:34 Jasmine, Princess HOSPICE methadone oral conc (Methadose) 10 mg/1 mL (1 mL) Conc 2 Waste 5 mg 3040737300 2/3/2018 21:34 Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Waste 1 mg 3040804621 2/3/2018 21:35 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Waste 10 mg 3040824405 2/3/2018 21:35 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Waste 10 mg 3040824405 2/3/2018 21:35

Jasmine, Princess HOSPICE HYDROmorphone (Dilaudid) 4 mg Tab 2 Remove 1 Tab 3040800298 2/5/2018 7:49 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040804621 2/5/2018 8:08 Jasmine, Princess HOSPICE HYDROmorphone (Dilaudid) 4 mg Tab 2 Remove 1 Tab 3040800298 2/5/2018 10:08 Jasmine, Princess

HOSPICE


2 Remove

1

Conc

3040815395

2/5/2018 10:41


Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040804621 2/5/2018 13:11 Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040804621 2/5/2018 13:11

Jasmine, Princess

HOSPICE

HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Soln-Oral

2

Remove

2

Soln-Oral

3040824405

2/5/2018 13:12


Jasmine, Princess

HOSPICE


2 Remove

1

Tab

3040800298

2/5/2018 13:34

Jasmine, Princess

HOSPICE


2

Remove

3

Tab ER

3040800298

2/5/2018 13:35 Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040824405 2/5/2018 13:40 Jasmine, Princess

HOSPICE


2 Remove

2

Soln-Oral

3040824405

2/5/2018 18:02

Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Waste 1 mg 3040804621 2/5/2018 20:21 Jasmine, Princess HOSPICE clonazePAM (KlonoPIN) 1 mg Tab 4 Remove 1 Tab 3040824405 2/8/2018 9:25 Jasmine, Princess HOSPICE HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Soln-Oral 2 Remove 2 Soln-Oral 3040824405 2/8/2018 9:26 Jasmine, Princess

HOSPICE


2 Remove

1

Tab ER

3040848644

2/8/2018 10:20

C10


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments admin 1000 (documented 1516) admin 1000 (documented 1718) by another RN admin 1000 (documented 1718) by another RN no admin admin 1416 admin 2mg 1400 (documented 1417) pain score 4 admin 1500 (documented 1528) pain score 6 admin 1400 (documented 1436) pain score 8 cancelled admin 1514 no admin no admin - patient sleeping - returned no admin return no admin admin 1030 (documented 1132) no pain score admin 1000 (documented 1128)


admin 1000 (documented 1127) admin 1126 admin 1126 pain score 6 cancelled admin 1600 pain score 4 admin 1400 (documented 1334) pain score 6 admin 1400 (documented 1623) admin 1400 (documented 1333) pain score 4

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE




4

2

4

Remove

Remove

Remove

1

1

1

Conc

Conc

Tab

3040848644

3040815395

3040815395

2/8/2018 10:39

2/8/2018 11:22

2/8/2018 11:22

Jasmine, Princess HOSPICE HYDROmorphone (Dilaudid) 4 mg Tab 2 Remove 1 Tab 3040800298 2/8/2018 11:37 Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040824405 2/8/2018 13:45

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE




2

2

2

Remove

Remove

Remove

2

1

3

Soln-Oral

Tab

Tab ER

3040824405

3040800298

3040800298

2/8/2018 13:46

2/8/2018 14:54

2/8/2018 14:55

Jasmine, Princess HOSPICE morphine ER (MS Contin) 15 mg Tab ER 2 Remove Ca 0 Tab ER 3040800298 2/8/2018 14:56 Jasmine, Princess HOSPICE morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C 2 Remove 2 Conc 3040848644 2/8/2018 15:12 Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040848644 2/8/2018 16:44 Jasmine, Princess

HOSPICE


2 Remove

2

Soln-Oral

3040824405

2/8/2018 17:06

Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040860953 2/8/2018 20:19 Jasmine, Princess HOSPICE HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Soln-Oral 2 Return to b 2 Soln-Oral 3040824405 2/8/2018 20:32 Jasmine, Princess HOSPICE HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Soln-Oral 2 Remove 2 Soln-Oral 3040824405 2/9/2018 8:34 Jasmine, Princess

HOSPICE


2 Remove

1

Inj

3040860953

2/9/2018 9:12

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE



clonazePAM (KlonoPIN) 1 mg Tab

2

4

4

Remove

Remove

Remove

1

1

1

Conc

Tab

Tab

3040815395

3040815395

3040824405

2/9/2018 10:43

2/9/2018 10:43

2/9/2018 10:44

Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040848644 2/9/2018 11:14 Jasmine, Princess HOSPICE morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C 2 Remove 2 Conc 3040848644 2/9/2018 11:14 Jasmine, Princess HOSPICE morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C 2 Remove Ca 0 Conc 3040848644 2/9/2018 11:15 Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE

HOSPICE


HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Soln-Ora l



2

2

4

2

Remove

Remove

Remove

Remove

1

2

1

1

Conc

Soln-Oral

Tab

Conc

3040860532

3040824405

3040815395

3040848644

2/9/2018 13:46

2/9/2018 13:47

2/9/2018 14:41

2/9/2018 14:41

C11


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments no admin no admin no admin no admin - wasted whole dose delayed waste delayed waste - wasted whole dose delayed waste admnin 1000 (documented 1019) pain score 4 admin 1000 (documented 1017) pain score 2 -order for pain 4-10 admin 1125 (documented 1140) admin 1125 (documented 1140) pain score 6 admin 1400 (documented 1530) pain score 6 admin 1400 (documented 1532) pain score 4 no admin admin 1800 (documented 1912) pain score 4 admin 1912 admin 1912 pain score 6 delayed waste delayed waste no admin no admin no admin admin 1000 (documented 1131) no pain score admin 1000 (documented 1112) pain score 6 no admin admin 1000 (documented 1741) no pain score admin 1113 admin 1113 no pain score

Jasmine, Princess HOSPICE HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Soln-Oral 2 Remove 2 Soln-Oral 3040824405 2/9/2018 18:18 Jasmine, Princess HOSPICE LORazepam (Ativan) 1 mg Tab 4 Remove 1 Tab 3040815395 2/9/2018 18:20 Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040848644 2/9/2018 18:21

Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040848644 2/9/2018 18:21 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Waste 15 mg 3040860532 2/9/2018 19:52

Jasmine, Princess

HOSPICE


2

Waste

10

mg

3040848644

2/9/2018 19:52

Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Waste 10 mg 3040848644 2/9/2018 19:53

Jasmine, Princess

HOSPICE


2

Remove

1 Inj

3040865481

2/12/2018 9:51

Jasmine, Princess

HOSPICE


2

Remove

1 Conc

3040861878

2/12/2018 9:52




Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040865481 2/12/2018 14:41 Jasmine, Princess HOSPICE morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C 2 Remove 1 Conc 3040864179 2/12/2018 16:22 Jasmine, Princess

HOSPICE


2

Remove

1 Inj

3040865481

2/12/2018 18:16

Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040865481 2/12/2018 18:17 Jasmine, Princess HOSPICE morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C 2 Remove 1 Conc 3040864179 2/12/2018 19:16 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Waste 15 mg 3040861878 2/12/2018 19:19 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Waste 15 mg 3040861878 2/12/2018 19:20 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040861878 2/12/2018 19:45 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040865481 2/14/2018 8:14 Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040878393 2/14/2018 8:44

Jasmine, Princess

HOSPICE


2

Remove

1 Inj

3040878393

2/14/2018 8:44

Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Remove 1 Conc 3040861878 2/14/2018 10:03 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040878450 2/14/2018 10:04

Jasmine, Princess

HOSPICE


2

Remove

1 Conc

3040858346

2/14/2018 10:05

Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040878450 2/14/2018 10:55 Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040878450 2/14/2018 10:55

C12


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments no admin admin 1400 (documented 1740) no pain score admin 1400 (documented 1606) no pain score returned admin 1400 (documented 1702) pain score 4 no admin admin 1530 (documented 1555) pain score 10 admin 1606 no pain score admin 1606 admin 1624 admin 1624 pain score 10 no admin - wasted whole dose admin 1800 (documented 1739) pain score 2 - order for pain 4-10 admin 1800 (documented 1741) no pain score no admin delayed return delayed waste delayed waste delayed waste delayed waste - wasted whole dose delayed waste delayed waste delayed waste no admin admin 0900 (documented 1608) admin 0730 (documented 0942) no pain score admin 0830 (documented 1610) pain score 6 admin 1000 (documented 1136)


Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

2

Remove

Remove

1

1

Conc

Inj

3040858346

3040878450

2/14/2018 13:30

2/14/2018 13:31


HOSPICE


2

Remove

1 Inj

3040878393

2/14/2018 13:33


Jasmine, Princess

HOSPICE


2

Remove

2 Conc

3040881934

2/14/2018 15:28

Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040878450 2/14/2018 15:59 Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Remove 1 Inj 3040878450 2/14/2018 16:00 Jasmine, Princess HOSPICE LORazepam (LORazepam Inten) 1 mg/0.5 mL (0.5 mL) Conc 4 Remove 1 Conc 3040881934 2/14/2018 16:18 Jasmine, Princess HOSPICE morphine (morphine Concentrate) 5 mg/0.25 mL (0.25 mL) C 2 Remove 2 Conc 3040881934 2/14/2018 16:19

Jasmine, Princess

HOSPICE


4

Remove

1 Inj

3040878393

2/14/2018 17:05

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

2

Remove

Remove

1

1

Inj

Conc

3040878393

3040858346

2/14/2018 17:05

2/14/2018 18:26 Jasmine, Princess HOSPICE morphine (Morphine) 150 mg/30 mL (30 mL) Inj 2 Remove 1 Inj 3040878450 2/14/2018 18:55 Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess


morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj

2 2 4 4

Return to b Waste Waste Waste

1 10

1 1

Conc mg mg mg

3040861878 3040847414 3040878450 3040878450

2/14/2018 22:41 2/14/2018 22:42 2/14/2018 22:42 2/14/2018 22:42


HOSPICE HOSPICE


4 4

Waste Waste

1 1

mg mg

3040878393 3040878393

2/14/2018 22:43 2/14/2018 22:43


HOSPICE HOSPICE


2 2

Waste Waste

15 15

mg mg

3040861878 3040861878

2/14/2018 22:43 2/14/2018 22:43


Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE

HOSPICE





4

2

2

4

Remove

Remove

Remove

Remove

1

1

2

1

Conc

Inj

Inj

Inj

3040890190

3040878906

3040878500

3040878500

2/17/2018 7:43

2/17/2018 7:44

2/17/2018 8:13

2/17/2018 8:14

C13


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments cancelled admin 1000 (documented 1131) no pain score hung 1030 (documented 1503) admin 1000 (documented 1132) no pain score admin 1000 (documented 1136) pain score 6 admin 1400 (documented 1609) no admin no admin admin 1135 no pain score admin 1400 (documented 1609) pain score 6 admin 1400 (documented 1502) no pain score admin 1000 (documented 1502) no admin hung 1445 (documented 1504) no admin admin 1511 (documented 1607) no admin no admin no admin no admin no admin delayed waste delayed waste delayed waste - wasted whole dose delayed waste delayed waste delayed waste delayed waste

Jasmine, Princess HOSPICE HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj 2 Remove Ca 0 Inj 3040878500 2/17/2018 8:14 Jasmine, Princess

HOSPICE


2 Remove

1

Inj

3040878906

2/17/2018 9:20

Jasmine, Princess

HOSPICE


2 Remove

1

Inj

3040824405

2/17/2018 10:00

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

2

Remove

Remove

1

2

Inj

Inj

3040890190

3040878500

2/17/2018 10:00

2/17/2018 10:57

Jasmine, Princess

HOSPICE


4 Remove

1

Inj

3040878500

2/17/2018 10:57


HOSPICE HOSPICE

morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj

2 4

Remove Remove

1 1

Conc Inj

3040886453 3040886453

2/17/2018 11:12 2/17/2018 11:12


Jasmine, Princess

HOSPICE


2 Remove

2

Inj

3040878500

2/17/2018 12:41

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE



2

4

Remove

Remove

1

1

Inj

Tab

3040878906

3040824405

2/17/2018 12:41

2/17/2018 12:42

Jasmine, Princess HOSPICE morphine (Morphine Sulfate PF) 2 mg/1 mL (1 mL) Inj 2 Remove 1 Inj 3040890190 2/17/2018 13:56 Jasmine, Princess

HOSPICE

morphine (Morphine) 150 mg/30 mL (30 mL) Inj

2 Remove

1

Inj

3040890190

2/17/2018 14:31


Jasmine, Princess

HOSPICE


4 Remove

1

Inj

3040890190

2/17/2018 15:11

Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess Jasmine, Princess

HOSPICE HOSPICE HOSPICE HOSPICE HOSPICE

HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj HYDROmorphone (Dilaudid) 1 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj

2 4 2 2 4

Remove Remove Remove Remove Remove

2 1 1 2 1

Inj Inj Inj Inj Inj

3040878500 3040878500 3040878906 3040878500 3040878500

2/17/2018 15:25 2/17/2018 15:26 2/17/2018 17:48 2/17/2018 17:49 2/17/2018 17:49


HOSPICE HOSPICE


4 4

Waste Waste

1 1

mg mg

3040878500 3040878500

2/17/2018 19:30 2/17/2018 19:31


HOSPICE HOSPICE


4 4

Waste Waste

1 1

mg mg

3040878500 3040878500

2/17/2018 19:31 2/17/2018 19:31



LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc

4 4 2

Waste Waste Waste

1 1

15

mg mg mg

3040890190 3040886453 3040886453

2/17/2018 19:32 2/17/2018 19:33 2/17/2018 19:33


C14


UserName Device MedDescription MedCl Transactio Quant QtyUOM ID TransactionDateTime comments admin 1000 (documented 1405) no pain score admin 1000 (documented 1412)


admin 1300 (documented 1411) admin 1400 (documented 1406) no pain score no admin no admin delayed waste delayed waste delayed waste

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

Jasmine, Princess

HOSPICE

HOSPICE

HOSPICE

HOSPICE

HOSPICE






2

4

4

4

2

Remove

Remove

Remove

Remove

Remove

1

1

1

1

1

Inj

Inj

Tab

Inj

Inj

3040878906

3040878500

3040824405

3040890190

3040878906

2/18/2018 9:22

2/18/2018 9:23

2/18/2018 9:23

2/18/2018 9:54

2/18/2018 13:08



morphine (Morphine Sulfate PF) 4 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj

2 4 4 4

Remove Remove Waste Waste

1 1 1 1

Inj Inj mg mg

3040878906 3040878500 3040878500 3040878500

2/18/2018 17:48 2/18/2018 17:49 2/18/2018 19:21 2/18/2018 19:21

Jasmine, Princess HOSPICE LORazepam (Ativan) 2 mg/1 mL (1 mL) Inj 4 Waste 1 mg 3040890190 2/18/2018 19:22 Jasmine, Princess HOSPICE morphine oral conc (Morphine) 20 mg/1 mL (1 mL) Conc 2 Waste 10 mg 3040890752 2/18/2018 19:23

C15


Factor Count

Total number of CS transactions by this RN in one month (Withdrawal, Return, Waste)

379

Inappropriate/lack of pain score 120

Whole dose waste 8

Unaccounted for (withdrawal, return, waste, administration don’t add up)

105

EXAMPLE CSUMMARY

Adminis t ra t ion Issues

C16

EXAMPLE D


Tr y i t :I ’ve a l ready matched the ADM repor t to the EHR repor t .

Mark any problem areas on the fo l lowing repor t pages. Then, determine what the main method of d ivers ion i s here and document on the summar y page.

Time: 10 minutes


D1


D2


D3


EXAMPLE DSUMMARY

D4

Method of Diversion Whole dose waste

Number of related instances

14 Percocet tabs wasted

Other comments Also a few instances where med had been documented as administered and wasted (couldn’t have been both)Questions about whether this nurse was caring for some of the patients

EXAMPLE E


Delayed waste – divers ion?


E1


E2


E3


E4


E5


E6


E7


E8


E9


E10


E11


E12


E13


E14


E15


E16


E17


E18


E19


E20


E21


E22


E23


E24


E25


E26


E27


E28


E29


E30


Things to consider

On review by chief of anesthesia, some doses seemed higher than necessary for patient condition

Documentation issues

Missing waste

Severely delayed waste (in some cases, several days later)

EXAMPLE ESUMMARY

Is th is d ivers ion?

E31

QUESTIONS Contact:

Luke Overmire

3 1 2 . 9 7 2 . 0 0 7 1

l u k e @ d i ve r s i o n s p e c i a l i s t s . c o m


Documents

UNRAVELING AUTOMATED DISPENSING SYSTEM REPORTS