Registered Pharmacist
Anyone ever had a CD discrepancy they couldn't resolve?
At the end of today, I had one tablet of dexamphetamine missing. Checking back the register, everything seems to balance until todays entry. However the tablets were dispensed by act and re-counted by me. So unless there was one slipped in between a PIL somewhere - thats all I can think of.
I'm work as a relief and feel horrible that I have to leave it for the perm. pharmacist to follow up...
so what would really happen if its un-resolved?
Tai Chi Enhanced Member
Difficult to tell, now, but I suspect its on the floor somewhere.
I've said it before, I'll say it again,
ALWAYS balance the register BEFORE dispensing a CD , as well as after.
There is no better way of keeping track. If the register is not correct, nothing gets done or dispensed until its witnessed and rechecked, and the superintendant's office informed. It only takes 10mins to do all of that.
....just my opinion
An beagle le dearcadh
Nothing will happen..please do not worry.Originally Posted by posey
The concept of CD register reconciliation is in place, quite rightly, to quickly bring to light discrepancies which point to either theft or erratic dispensing and checking procedure.
One tablet here or there would never be an issue.
Good practice here, I think, would be to make a second register entry showing actual balance of tablets, initial, and date it. The balance will then be correct, and if anyone wants to go looking for the one errant tablet, then let them.
Fleegle.
Loyal Member
...Errr. Surely if the 'one tablet here or there' was always the same specific drug then actually it would be an issue. I agree that a single occurence of a single missing tablet would not become an issue but if there was a pattern of such occurences then it ought to become an issue (staff theft)
Newly registered in 1981
Have had instances of Pethidine blisters being empty - ie sealed empty (not tampered with). This would be logged in the CD register as a discrepancy - we even kept the blister in the CD cupboard as evidence....Errr. Surely if the 'one tablet here or there' was always the same specific drug then actually it would be an issue. I agree that a single occurence of a single missing tablet would not become an issue but if there was a pattern of such occurences then it ought to become an issue (staff theft
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Record what you find and do what you can to rectify it.
An beagle le dearcadh
Agreed, however may I ask that you quote my complete post in future..and not just the parts that suit your reply.......Errr. Surely if the 'one tablet here or there' was always the same specific drug then actually it would be an issue. I agree that a single occurence of a single missing tablet would not become an issue but if there was a pattern of such occurences then it ought to become an issue (staff theft
'The concept of CD register reconciliation is in place, quite rightly, to quickly bring to light discrepancies which point to either theft or erratic dispensing and checking procedure.' was also an integral part of my original post.
Thanks...
Fleeg.
Last edited by Fleegle; 1st, April 2009 at 08:37 PM. Reason: Clarification.
Loyal Member
Sorry Fleegle, it wasn't my intention to misrepresent your point of view and I do agree with the overall sentiment of your reply. Point taken.
My main concern is that if pharmacists/techs selectively *ignore* small discrepencies (e.g. a single tablet missing) for fear of getting into trouble themselves then by doing so they could be preventing the detection of something much bigger. If you can't detect the source of an error within the pharmacy then it is you duty to report this.
If for example a locum was working in a different pharmacy every day, and stealing a *single* tablet every day then this would only be picked up if the AO at the PCT is informed of each incident allowing him/her to detect that there might be a significant problem.
As has been rightly pointed out, I can't imagine (would certainly hope not anyway) that an individual pharmacist would find themselves in trouble because a single tablet is noticed to be missing while they are in charge.
Registered Pharmacist
thanks for the replies. Feeling much assured to know that there shouldn't be much trouble.
Reported it to the apm and let the perm. pharm know, so its out of my hands now..
Tai Chi Enhanced Member
I'm sure you and Fleegle (and others) are right, there won't be any trouble over one tablet; even so, I got a fax today from the local accountable officer (who happens to be a pharmacist) that tells me that a few containers of diamorphine 10mg (Aurum pharm ltd) contained:
a. 99 tabs not 100
b. 99 and a half tabs not 100, and
c. 99 and two halves, not 100 wholes!
I wonder if we'll hear about the 101s etc. in due course!
....just my opinion
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