Control Drugs by Chen Jing

minons123456 — 2025-07-04 00:14:35 UTC

IV Fentanyl 50mcg PRN was prescribed for Mdm. Fatimah. At 1400hrs, the anesthetist indicated his intention to administer the medication. The RN retrieved a 100mcg/2mL vial of Fentanyl from the Automated Dispensing Cabinet (ADC). The anesthetist diluted the Fentanyl with a compatible diluent to a total volume of 4mL (100mcg/4mL) and administered 2mL (equivalent to 50mcg) to the patient. The remaining 2mL was handed back to the RN, who placed the syringe in a biohazard bag and returned it to the pharmacy.

Identify what is wrong in handling CD drugs.
State the correct workflow accordingly to hospital protocol.

minons123456 — 2025-07-09 06:27:42 UTC

The doctor prescribed Oxycodone 5mg capsules every 6 hours as needed for Mr. Tan following his surgery. On post-operative day 2, Mr. Tan requested to take the medication half an hour before his exercise session. The RN withdrew the medication from the Automated Dispensing Cabinet (ADC) in preparation to administer it, but Mr. Tan declined, stating he wanted to attempt exercising without the painkiller. At that moment, another patient called for assistance, and the RN placed the medication on the nurses’ counter before attending to the patient. It was only at the end of the shift that the RN realized she had left the medication unattended at the counter. Upon checking, the medication could no longer be found.

Identify what is wrong in handling CD drugs.
State the correct workflow for this incident.

minons123456 — 2025-07-09 06:29:01 UTC

The doctor prescribed oral morphine 10mg twice daily for Mr. Lee. RN A, who was the nurse-in-charge, requested RN B to witness the withdrawal of the controlled drug (CD) from the Automated Dispensing Cabinet (ADC). However, RN B returned to her own station to attend to her patients. RN A proceeded to administer the oral morphine 10mg to Mr. Lee alone. After the administration, RN A approached RN C to countersign the CD administration retrospectively.

Identify what is wrong in handling CD drugs.
State the correct practice accordingly to hospital protocol.

minons123456 — 2025-07-09 06:29:49 UTC

The doctor had prescribed 2.5mg of subcutaneous Morphine Sulphate to be administered every 6 hours. When the dose was due, the RN prepared the medication; however, the patient’s husband objected and requested that the dose be reduced to 1mg. The RN informed the doctor-on-call, who subsequently revised the order to 1mg. To comply with the new order, the RN expelled 1.5mg of the already prepared 2.5mg dose onto a tissue paper. After doing so, just as the RN was about to administer the 1mg dose, the patient’s husband again refused the medication.

Identify what is wrong in handling CD drugs.
State the correct practice accordingly to hospital protocol.

minons123456 — 2025-07-09 06:35:17 UTC

SN A and SN B retrieved a Morphine ampoule from the Automated Dispensing Cabinet (ADC). SN A placed the ampoule in a kidney dish on the medication cart. While transporting the cart to the patient, a strong gust of wind caused the kidney dish to fall, resulting in the ampoule breaking on the floor.

What should be done?

minons123456 — 2025-11-12 11:20:38 UTC

90-year-old Mr X was admitted with multiple comorbidities. His primary diagnosis was pneumonia. After the review by MO, the patient was placed on partial code and for palliative care. Patient de-saturated to 67% with non-rebreathing mask 15L/min @ 0245am.The HO was called in by the RN to check the patient and was escalated to MO. Verbal order was given to the RN to give SC Morphine 1mg using non-retractable winged needle.

An Override Pull was made by 2 RNs to take 1 ampoule of morphine (10mg/ml) from ADC, but both RNs could not find the non-retractable winged needle. The RN gave the morphine ampoule, 3mL syringe and Saline for flushing to the MO and went to attend to another patient. The MO gave the injection intravenously (IV), without counterchecking and gave 10mg instead of 1mg.

What are issues that you have identified in this case?
What are the DO's and DONT's when handling CD drugs?