On night shift, you notice 14 morphine tablets are missing from the register; what is the most appropriate initial action?

On night shift, you notice 14 morphine tablets are missing from the register; what is the most appropriate initial action?

• A. Do nothing
• B. Inform the pharmacy manager
• C. Return to supplier
• D. Call the police

Answer: (B)

When a controlled substance goes missing, the first step is to escalate to the person in charge to start the proper internal response. Informing the pharmacy manager immediately ensures the situation is handled through the correct procedures, including locking down the remaining stock, initiating an incident report, and beginning a medication reconciliation. The manager can determine whether there was a documentation error, a dispensing mistake, or actual diversion, and decide on the next steps. Choosing to do nothing delays detection and accountability. Returning the stock to the supplier isn’t appropriate without first confirming what happened to the missing tablets. Reporting to the police is not the initial action; internal investigation and appropriate regulatory reporting come first, when required, after the manager assesses the discrepancy.

When a controlled substance goes missing, the first step is to escalate to the person in charge to start the proper internal response. Informing the pharmacy manager immediately ensures the situation is handled through the correct procedures, including locking down the remaining stock, initiating an incident report, and beginning a medication reconciliation. The manager can determine whether there was a documentation error, a dispensing mistake, or actual diversion, and decide on the next steps.

Choosing to do nothing delays detection and accountability. Returning the stock to the supplier isn’t appropriate without first confirming what happened to the missing tablets. Reporting to the police is not the initial action; internal investigation and appropriate regulatory reporting come first, when required, after the manager assesses the discrepancy.