What To Do When the Count Doesn’t Add Up

A drug diversion is one of those events that no facility wants to face. An incorrect narcotic count isn’t just a paperwork problem – it’s a potential patient safety issue and a serious compliance concern. Are you and your team ready to respond if counts don’t add up?

Although we can never be truly prepared for a discrepancy to occur, one of the best ways to prepare is to practice. A mock drill gives you and your staff the chance to rehearse a response in the event this happens.

The Scenario: A Missing Narcotic – The Count Doesn’t Add Up

It’s the end of a busy surgical day. The final narcotic count is underway when it is discovered that two vials of fentanyl are unaccounted for – how will you and your staff respond?

Steps to Consider:

Discovery
The discrepancy is discovered during the count. Does your team know what immediate steps to take and who to notify?

Containment
Who is allowed to leave? Staff should be asked to remain onsite until excused to allow for initial investigation to be complete. An immediate audit should check for any other concerns. If the facility has surveillance, video footage should be pulled to support the investigation.

Investigation
What initial steps should be taken to determine the problem? Is it just a documentation issue or has there been a diversion? A review of the narcotic log and related documentation should begin immediately. Staff should be assigned to retrace the steps that may have lead to the discrepancy – when were the vials last accounted for? Who handled them? Staff involved should be interviewed and their statements documented to help piece together the events that lead to the discrepancy. An incident report should detail what’s known and what actions are underway.

Notification
Does the facility understand the reporting responsibilities in the event of a diversion? Once internal investigations are complete, outside authorities may need to be contacted if diversion is suspected.

Responding to an Incorrect Count: How a Diversion Drill May Improve Outcomes

Conducting a drug diversion drill prepares you and your team for response if an incorrect count occurs. As with any drill, preparation teaches everyone what is expected and their role if a real-life problem occurs. A Drug Diversion Drill helps the team identify the difference between a process mistake and an intentional diversion – both of which require a planned, coordinated response.

Drills aren’t just about checking off a regulatory requirement – they’re about protecting patients, staff, and your facility’s reputation. They’re proof that your team takes safety seriously and is ready to respond when needed.

When people practice together, they build trust in each other and the process. That trust means when the real thing happens, your team will know exactly what to do.

Debriefing: Why It Matters

The best part of any drill is the discussion afterward. Once the drill concludes, everyone meets to debrief and review what happened. Here’s where everyone can discuss what worked and what didn’t. Ask for honest feedback from your staff.

• What worked, what didn’t, and what would make it better?
• Was the issue identified and reported quickly?
• Did the team follow facility policy?
• Were the correct people notified?
• Did the team escalate the situation appropriately?
• Was the discrepancy resolved? If so, how?
• Was the response thorough and documented well?
• Was this really a diversion, or something else—like a simple counting error?

Debriefings allow the team to discuss any knowledge or protocol gaps.

Turning Lessons Into Action

Use what you learn from each drill and debrief session:

• Review policies and update as needed to keep them aligned with what is learned.
• Schedule in-service training as training needs are identified.
• Continue to use mock scenarios to test real-life potentials.
• Track corrective actions so improvements don’t fall through the cracks.

Final Thoughts

Drug diversion is a risk that every facility must take seriously—but your response doesn’t have to be left to chance. By conducting diversion drills, you empower your staff, strengthen your protocols, and protect your patients. The time to prepare is before there’s a problem. With practice, you’ll be better prepared for whatever comes your way.

We’ve created a Drug Diversion Drill Form you can download and use to prepare your facility.

You can find the form here: Drug Diversion Drill Tool