When something goes wrong with a patient or a med

The narcotic count is off at shift change

The count is off and the off-going nurse is already in her coat. What to write, who signs, and why you never sign on trust.

9 min read built on 6 full opinions updated 2026-10-04

Written by a med-surg RN, ten years, day shift. Why there is no name on it

Denise reacting to this topic
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You're at the cart with the oncoming nurse, and one card, vial, or bottle doesn't match the sheet. A tab short. More liquid than there should be. A removal with no signature. Here's what goes on the count sheet, what goes in the report, who signs, and why you only sign for a count you did yourself.

The short version

  • Don't leave, and don't let the other nurse leave. You're both still on the unit, so check the obvious causes together before anyone signs: an unsigned removal, a waste with no witness, a card in the wrong slot, a pharmacy delivery nobody entered.
  • Write the actual number on the count sheet. Put down what you physically counted, not what the sheet says should be there. Mark it as a discrepancy. Both of you sign, with the time.
  • The story goes in the variance or incident report. It doesn't go in the patient's chart. The chart gets an entry only if a patient's dose was actually affected, like a dose that was due and not given.
  • Tell the charge nurse or supervisor before either of you goes home. Then follow your facility's policy. Pharmacy and the DON usually get pulled in.
  • Only sign a count you actually did. Your signature means you saw the right number. If you didn't count, or the count is off, the sheet should say that in plain words.

What to write instead

On the count sheet

How it often gets written Better
Count correct with two initials, when the count wasn't actually done togetherCount done together at 1905 by [both names]. Oxycodone 5 mg card #A: sheet 12, actual 11. DISCREPANCY. Charge RN notified 1910.
Writing a new number over the old oneSingle line through 12, written 11, initials, date, time. See variance report #__.
Leaving the line blank because the count is offCount NOT verified — discrepancy under review, see note. [initials] [time]
Morphine OKMorphine 20 mg/mL oral solution: expected 15 mL, measured 34 mL. Overage. Not used, set aside, charge RN and pharmacy notified [time].

In the variance or incident report

How it often gets written Better
Count was off, probably a charting issueAt 0705 count with [RN name], hydrocodone/APAP 5/325 card for [room]: sheet 8, actual 7. Last removal signed 0200 by [name]. eMAR shows 0200 dose given. No 0400 removal on sheet; eMAR shows 0400 dose given by [name].
Pharmacy must have shorted usDelivery sheet dated [date] lists 30 tabs. Card holds 29 sealed blisters plus 1 empty blister with no removal signature.
Off-going nurse left before countOff-going RN [name] left the unit at 1915 before the handoff count. Charge RN [name] counted with me at 1930. Result: [number].

In the patient's chart (only if a dose was affected)

How it often gets written Better
Narcotic count off, see reportNothing about the count. The chart isn't the place for it.
Pain med given per MAR when you can't confirm itAt 0730 pt reports last pain med was at bedtime. Pain 7/10 R hip. Oxycodone 5 mg PO given 0735 per order. Reassessed 0835: 3/10.

Copy this

Count sheet entry (count is off)

`` [DATE] [TIME] Shift-change count by [OFF-GOING NAME, CREDENTIAL] and [ONCOMING NAME, CREDENTIAL], counted together at [CART / CABINET]. [DRUG, STRENGTH, FORM] for [PATIENT / ROOM]: sheet shows [EXPECTED], actual [COUNTED]. DISCREPANCY of [DIFFERENCE, SHORT / OVER]. All other items: count matches sheet. Charge RN [NAME] notified at [TIME]. See variance report #[NUMBER]. [SIGNATURE OFF-GOING] [SIGNATURE ONCOMING] ``

Count sheet entry (you were not able to verify)

`` [DATE] [TIME] Count NOT verified by [YOUR NAME, CREDENTIAL]. Reason: [OFF-GOING NURSE LEFT UNIT BEFORE COUNT / COUNT NOT DONE TOGETHER / ITEM NOT PRESENT AT CART]. Charge RN [NAME] notified at [TIME]. Count completed with [NAME, CREDENTIAL] at [TIME]: [RESULT]. [SIGNATURE] ``

Variance / incident report

``` Date/time discovered: [DATE] [TIME] Location: [UNIT], [CART / CABINET / ROOM] Persons present at count: [NAME, CREDENTIAL], [NAME, CREDENTIAL]

What was found: [DRUG, STRENGTH, FORM], [CARD / VIAL / BOTTLE ID IF ANY], for [PATIENT / ROOM]. Count sheet balance: [EXPECTED]. Physical count: [COUNTED]. Difference: [NUMBER] [UNITS], [SHORT / OVER].

What the records show: Last count matching sheet: [DATE] [TIME], signed by [NAMES]. Removals on count sheet since then: [TIME — NAME — AMOUNT, ONE PER LINE]. Corresponding MAR/eMAR entries: [TIME — NAME — AMOUNT, OR NONE FOUND]. Wastes recorded since then: [TIME — NAMES — AMOUNT, OR NONE]. Pharmacy deliveries since then: [DATE — AMOUNT — SIGNED BY, OR NONE].

Actions taken: Item [SECURED / SET ASIDE / LEFT IN PLACE] at [TIME]. Notified: charge RN [NAME] at [TIME]; [SUPERVISOR / DON / PHARMACY] [NAME] at [TIME]. Patient dose affected: [NO / YES — DESCRIBE AND NOTE PROVIDER NOTIFIED AT TIME].

Reported by: [NAME, CREDENTIAL] [SIGNATURE] [DATE] [TIME] ```

Message to charge nurse or supervisor

`` [NAME], at [TIME] shift-change count on [UNIT] with [OTHER NURSE NAME], [DRUG, STRENGTH] for [ROOM] is [NUMBER] [SHORT / OVER]: sheet [EXPECTED], actual [COUNTED]. We are both still on the unit. Item is [SECURED / SET ASIDE]. Count sheet marked as discrepancy and signed by both of us. I am starting the variance report now. Please advise on next steps per policy. [YOUR NAME], [CREDENTIAL], ext [NUMBER] ``

Words that do the damage

Word or phrase Why it's a problem Use instead
count correct (when it wasn't counted)Says you verified something you didn'tcount not verified plus the reason
probably, must have, likelyA guess about the cause, not something you sawWhat you saw: numbers, times, names on entries
stolen, diverted, missing because ofAccuses someone. That's the investigation's jobdiscrepancy, sheet shows X, actual Y
pharmacy errorAssumes a causedelivery sheet lists X, received Y
fixed, corrected (with no trail)Hides what the number was beforeSingle line through, new value, initials, time, reference to the report
OK, fine, WNL for a countNo number, so nobody can check itThe actual count for each item

If you remember one thing

Sign for the number you actually counted. Didn't count? Write that down.

What goes wrong

The most common mistake: sign now, sort it out later. Everyone's tired and the off-going nurse wants to go home. So you initial the sheet and plan to bring it up.

Here's the problem. A count sheet is a relay baton. Each signature says the number matched at this time, with this person. When a shortage turns up later, people work backward to the last pair of signatures that said everything was fine. Sign without counting and you're now part of that pair. You've also erased the most useful thing anyone had: when the count went wrong.

A few related mistakes do the same damage:

  • A removal on the count sheet with no matching administration in the MAR or eMAR. Two records that should match don't. That mismatch is the discrepancy, whatever caused it.
  • Writing over numbers on the count sheet. Maybe you're just fixing a typo. To anyone reading it later, it looks like someone changed the count.
  • Ignoring an overage. Too much is a discrepancy too. With liquids it can be the more worrying kind.
  • Leaving a discontinued card off the count because it's in a basket waiting for pharmacy. Until it's handed off and signed for, you count it.
  • Leaving without a handoff count. No count, and nobody can say when the number changed.

What the guidance says

It is not hypothetical

What happened in 5 court cases — tap to read

King v. Garfield County Public Hospital District No. 1, District Court, E.D. Washington, 2014. This is an ordinary shift change on paper. The hospital described its routine this way: "Nurses also perform a narcotic count at the end of each shift and sign to indicate who is responsible for the count." A nurse signed the count log at the end of his shift. Next morning another nurse found a 19 mL overage in a morphine bottle. Someone else had signed out doses overnight. The bottle wasn't tested. It went back to the manufacturer and was destroyed. Staff were drug-tested, and the nurse was later fired after a positive result he said came from his own codeine prescription. The count log is the record of who was responsible and when. And note what started all of it: an overage, which set things off just as a shortage would have.

O'Malley v. NaphCare, Inc., District Court, S.D. Ohio, 2014. A charge nurse at a jail was fired. Her discharge summary named her as the nurse who "was responsible for the Narcotic Count" on the shift when a pharmacist found one Ativan tab missing from a blister card. It also said she left without making sure the count got done and the keys went to the next shift. She sued for defamation, saying the narcotics were never actually missing. The court didn't decide whether that was true. It only let her claim go forward, noting that the summary "clearly states that she was responsible for the narcotics at the time they went missing." Your name on the count ties you to the discrepancy.

Robyn L. Spradlin v. State of Indiana, Indiana Court of Appeals, 2025. At this facility the narcotics count sheet (NCS) recorded removals from the cart, and the eMAR recorded administration. In the court's words: "The NCS tracks inventory but does not verify patient administration -- only the eMAR serves that function." An investigator found more than forty removals on the count sheet with no matching eMAR entry. The jury acquitted the nurse of obtaining controlled substances by fraud and convicted her on a records charge. The appeals court reversed that conviction because the State never proved that a law under the specific statute required the eMAR entry. She won in the end. But the mismatch between the two records is what started the investigation and kept it going.

Continued Care, Inc. v. Fournet, Texas Court of Appeals, 9th District (Beaumont), 1998. All we have here is a dissent. According to it, the majority reversed a jury verdict against the nursing home. The testimony it describes shows what bothered staff about the Demerol records: a vial count that went up between two dates, waste recorded as an unknown liquid, and a nurse who said entries on the narcotic count sheet "looked like they had been written through or over". That's testimony as the dissent tells it, not a court finding. It still shows you what people notice. Write-overs. Counts nobody can explain.

Stewart v. Missouri Department of Health & Senior Services, Missouri Court of Appeals, 2017. A med tech pulled a discontinued opioid card off her cart and handed it, with its count sheet, to the charge nurse to go back to pharmacy. The card never got there. That was one piece of evidence in a larger misappropriation finding, and it put the nurse on the state's Employee Disqualification List. The court affirmed. So a discontinued card needs a signed handoff at every step until pharmacy has it in hand.

Read the decisions yourself

Every case below is a published decision on CourtListener. Open them. Nothing on this page asks you to take our word for what a court said — and where we only had the search result rather than the full opinion, it says so.

All the decisions behind this guide, in one page — searchable by court, year, or what happened.

What people say on the floor

Nurses talking to each other about this, quoted as they wrote it. This is opinion, not a source. It is here because it shows what the argument actually is — the rules above come from the decisions and the published guidance, not from these threads.

  • Ours only presents controlled substances that have been accessed since the last time they were counted. ... Yes, I (we) do count everything. ... We count narcotics that have been pulled at each Pyxis nightly.

    r/nursing on Reddit: Narcotic count reddit

  • Sometimes the count gets messed up by pharmacy and that throws it all off. Sometimes someone else screws up the count. A lot of things can screw up a count. ... We do a med count at change of shift so surprises don’t happen. ... We do change of shift med counts too with 2 nurses but some RNs have be

    r/nursing on Reddit: Missing Narcotic- need advice reddit

  • There's double staffing for at least half an hour at shift change, and the drugs get manually counted and checked against an online or written log. I've never seen a real discrepancy, occasionally there's a miscalculation in the written books ...

    r/nursing on Reddit: What's your hospital's policy on accidentally taking narcotics home ( reddit

  • If the count is off and your initials or signature is on the form and it gets taken to a higher level (or even court), you will have a difficult time explaining why you're performing an official duty off the clock... especially when narcotics are involved. ... interesting perspective. I wonder

    r/nursing on Reddit: How to say no to doing narcotic count before my shift? reddit

What everyone else says

Guidance from professional bodies, insurers and other people who write about this. Useful, but it is advice, not law — that part is above.

How would you chart it?

This is the part we cannot research. If you have a way of writing this that has held up — put it here. No account, no name needed. Nothing that could identify a patient: no room numbers, no dates of birth, no MRNs. Use placeholders, the example still works.

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