A controlled drug register is a bound book, written in ink, signed by two people for every dose, and checked against a physical count. Ours balances to the ampoule, every time, on a ward where the arithmetic says it cannot.
I have worked in hospital pharmacy for seventeen years and controlled drugs are my responsibility on six wards.
The register is worth explaining because nothing about it is casual.
Each ward has a bound book with numbered pages, one drug and strength per page. Every time a dose is given, two registered nurses sign: one who gave it and one who witnessed. The entry has the date, the patient, the dose, and the running balance.
The stock is in a locked cupboard inside a locked cupboard, and the key is held by the nurse in charge and handed over shift by shift with a signature.
And the balance in the book is checked against a physical count. On my wards that is weekly, by me and a nurse together, and we count the ampoules.
If the book says fourteen there must be fourteen in the hand. A discrepancy of one ampoule is an incident report, an investigation and, often, a police referral, because the commonest reason for a missing controlled drug is a member of staff taking it.
Ward 9's register balances. Always.
Seventeen years is a long time and I have checked thousands of registers, and in that time I have seen perhaps sixty discrepancies. Almost all are arithmetic: somebody carried a balance wrong, or a page turned and a line was missed, and it is found and corrected the same day.
Ward 9 has never had one. Not a miscount, not a carried balance, not a transposed figure.
That is the part that took me nine years to see as strange rather than admirable.
The nurses on ward 9 are not better at arithmetic than the nurses on ward 8. They are the same people, on the same rotation, often literally the same person on a different night.
A register kept by human beings under pressure, in ink, at three in the morning, for eleven years, with no error at all is not a well run ward. It is a thing that does not happen.
What made me start looking properly.
In 2022 I found an error while it was being made.
I was at the cupboard with a staff nurse doing the weekly count, and she wrote the new balance on the page and it was wrong by one. I saw it as she wrote it. She had carried eighteen from the line above instead of seventeen.
I said so. She looked at it and agreed and started to draw a line through it, which is the correct way to correct a register: strike once, initial, write the correct figure beside it.
The figure on the page was seventeen.
Not corrected. There is no strike and no initial anywhere on that page and I have looked at it perhaps two hundred times since. The line reads seventeen and it always has.
She saw it too. She stood there with the pen and she said something like, oh, I have written it right, and we counted the ampoules and there were seventeen, and we both signed.
I did not report that, and I want to be plain that not reporting it is the most serious thing in this account.
What would I have written. That a colleague made an error which then was not there. There is no incident category for it and the first question would have been about me.
So I did what a technician does, which is start keeping my own record.
Since 2022 I photograph ward 9's pages at every count. Not for evidence. Because I wanted to know whether a page ever changes between counts.
Seventy one weeks of photographs.
No page has ever changed. Every entry is in the hand that made it and the ink is the ink and nothing has moved.
The errors do not get corrected. They do not get made.
The stock itself.
This is where I have to be careful about what I actually know.
The count is the count. When the book says fourteen there are fourteen ampoules, and I have held them, and the batch numbers are the batch numbers we were issued.
There has never been a drug on that ward that pharmacy did not send, and there has never been one missing.
The ward's usage is normal for its case mix. I have compared it to three similar wards and ward 9 sits in the middle.
So nothing is being taken and nothing is appearing. The drugs are right. It is only the writing that never goes wrong.
One other thing, and it is the reason I finally wrote this down.
The register has a column for the witness, and every dose has two names in it.
I did an audit in the March, for a completely different purpose, which was checking that witnesses were registered staff on duty at the time, because that is a real compliance requirement and it is the kind of thing that gets picked up in an inspection.
Every witness on ward 9 for the last three years was on duty. All of them, on the roster, at the time, on that ward.
Except that on eleven occasions across those three years, the same second signature appears, in the same hand, and the name is a name that has never been on our staff list.
I checked it against the trust's establishment going back to 2011, which is as far as the system goes, and against the professional register, where there is one person with that name and she has never worked here.
What I do about it.
I sign the count. The count is right and the drugs are right and my signature says the balance in the book matches the stock in the cupboard, which it does, every week, exactly.
I have not raised the eleven signatures. There is a form for it and I have opened it four times.
What stops me is not fear of looking foolish. It is that the form asks what harm resulted, and the answer, in eleven years on a ward that has never once been short of a controlled drug, is none at all.