Nurses' Notes
0640: The charge nurse begins the controlled-substance safety review after receiving two concerns about a staff nurse. The record shows that the nurse completed the opening count with another RN. During report, the nurse accepted help organizing several routine medication passes. At 0715, the charge nurse observes that the nurse has slurred speech and an unsteady gait. The nurse states that no sleep was obtained overnight but remains assigned to clients. The electronic record confirms that the nurse logged out before leaving a medication terminal. At 0740, a client reports that pain relief followed the documented oral analgesic. The schedule confirms that the nurse attended the required safety huddle before receiving the assignment. The charge sheet shows that the nurse documented the assigned rooms and emergency contact plan. The medication cabinet report then shows that a fentanyl vial is missing after the nurse's access. No waste, administration, or return entry accounts for that vial. A coworker notes that the nurse requested a second check for an insulin dose. At 0805, the charge nurse confirms that the nurse used two identifiers before a scheduled medication. Another client is found with new somnolence and 8 breaths per minute after no opioid was documented. The staff nurse cannot explain the client's change or the missing vial. The schedule shows that the nurse returned from a planned meal break on time. The charge nurse keeps the observations factual and begins the facility safety process.
護理紀錄
0640：護理長在接獲兩起關於一位護理人員的疑慮後，開始進行管制藥品安全審查。紀錄顯示該護理人員與另一位RN完成了開封計數。交班時，該護理人員接受協助整理數個常規給藥流程。0715時，護理長觀察到該護理人員言語含糊且步態不穩。該護理人員表示整夜未睡，但仍被指派照護個案。電子紀錄確認該護理人員在離開給藥終端機前已登出。0740時，一位個案表示在服用有紀錄的口服止痛藥後疼痛獲得緩解。排班表確認該護理人員在接受工作指派前參加了必要的安全會議。工作分配表顯示該護理人員記錄了負責的病房及緊急聯絡計畫。藥品櫃報告隨後顯示在該護理人員取用後，一支吩坦尼藥瓶遺失。沒有廢棄、給藥或退庫紀錄能解釋該藥瓶的去向。一位同事提到該護理人員要求為一劑胰島素進行雙重核對。0805時，護理長確認該護理人員在給藥前使用了兩種辨識方式。另一位個案被發現在無鴉片類藥物紀錄下出現新嗜睡且每分鐘呼吸8次。該護理人員無法解釋個案的變化或遺失的藥瓶。排班表顯示該護理人員準時從預定的用餐休息時間返回。護理長保持觀察事實，並啟動機構安全流程。