Those of us who work in the health care setting are always looking to provide safer care to our patients and one primary area of concern is the prevention of drug diversion.
All facilities that have controlled substances are faced with the reality of and need to safeguard against diversion. Thankfully, innovations by vendors, improved hospital policies, and increased security have improved the secure storage aspects of narcotics. However, one critical area of diversion prevention that lacks attention is staff and nursing leadership education regarding the recognition of diversion.
We all want to believe that we work with the best team and that no one would be “that one” that uses drugs. This misconception is a major barrier to investigations and monitoring for diversion. Roughly 10-15% of the staff of a facility could be impaired or in recovery1. Most facilities I have worked at only detect 2-4 diverters per year. This doesn’t mean it’s not happening, it means we are not looking hard enough.
How can we educate the staff and leaders to be watchful? What do staff and leaders need to know?
- Signs and symptoms of diversion (see chart)
- Medication dispensing systems reports
- Resources available to help the staff member
- Waste disposal practices
|Signs/Symptoms||Physical Signs||Behavioral Signs|
|Unexplained absence from work area||Shakiness, tremors, fatigue||Frequent mood changes, outbursts of anger|
|Medication errors||Slurred speech||Inappropriate laughter|
|Mood changes after meals or breaks||Frequent use of mouthwash or breath mints||Hyper or hypo-activity|
|Isolation from peers||Watery eyes||Lack of concentration|
|Frequent reports of lack of pain relief from assigned patients||Constricted or dilated pupils||Frequent accidents|
|Pyxis obsession; offering to do other nurses’ med pass||Diaphoresis||Frequent lying|
|Wasted narcotics assigned to single nurse||Unsteady gait||Frequent complaints of pain|
|Decreased quality of care, arrives late, leaves early||Disheveled appearance||Cold weather clothing in warm weather|
In addition to educating staff on the signs and symptoms of narcotic use, organizations need to also coach employees on how to spot individuals who may be diverting drugs to give or sell to others. Not all staff who divert are using the diverted medicines themselves.
I find case scenarios have been extremely effective in showing all the components of diversion. Some examples of those are:
- Nurse always removes Tylenol with Percocet and charts she is administering both at the exact same time. When she gave the patient the Tylenol and kept the Percocet herself.
- Nurse always asks a different person to waste medications drawn up in syringes. Nurse is wasting a “full dose” versus returning the full dose in the original package. Nurse withdraws the medication into a syringe or injects into a vial for them to take home. The syringe is then filled with normal saline for the actual waste.
- Nurse removes multiple narcotics on multiple patients outside of the scheduled times.These medications show up as not returned given or wasted. When nurse is confronted, his or her pockets and/or locker had various types of narcotics.
- Nurse’s patients always complain their pain is not relieved.
Educating staff gives them the confidence they need to recognize diversion, and the proper resource to whom they may report the information. I have found that experienced nurses are more comfortable reporting and confronting these situations. The novice nurse is often concerned with the reputation he or she will gain by turning in another staff member. Even trained leaders may find it difficult to confront a staff member suspected of diversion. Often the simple question of “can you tell me why…?” will yield useful information, but too often leaders feel a need to make things more complicated. In our experience, approaching staff with simple questions is the first line of monitoring.
The collaborative relationship with pharmacy is critical for diversion investigations, and many organizations have put together drug diversion committees. Committees review national cases, monitor compliance with medication administration policies, and often hire consulting firms to help identify and strengthen vulnerable areas in the organization. We all recognize that sometimes we are so close to the situation that we fail to see some of the opportunities for improvement that are in plain sight
All health care professionals have legal and ethical obligations to report suspected substance abuse. Knowing someone is diverting and choosing to ignore it puts your license at risk. The American Nurses Association Code of Ethics for Nurses:
- Do not ignore poor performance.
- Do not lighten or change the nurse’s patient assignment.
- Do not accept excuses.
- Do not allow yourself to be manipulated or fear confronting a nurse if patient safety is in jeopardy.
Educating staff on the simple rules to follow for drug administration and safety will protect staff and the organization from the legal ramifications of diversion. Our priority is always to protect the patient from harm.
- Never waste with anyone if you do not see the product and amount that is to be wasted.
- ALWAYS question why someone would be wasting an entire vial or syringe of product instead of returning.
- Do not hold extra medications until the end of shift – waste immediately.
- Only pull medications from the medication dispensing system that you will be administering right away.
- Follow the provider’s order explicitly.
- Document follow up pain scores.
- Notify your manager right away if you have concerns of diversion.
- Thomas CM, Seila D. The impaired nurse: Would you know what to do if you suspected substance abuse? Am Nurse Today. August 2011 Vol. 6 No. 8.