Nurse Drug Diversion and Nursing Leaders’ Responsibilities

1 ABSTRACTN urses who divert drugs pose significant threats to patient safety, but also become a liabilityto healthcare organizations and the Nursing department where the Diversion and Nursing leaders have a responsibility to ensure that security systems arein place to prevent Diversion and protect patients if Nursing impairment is suspected as aresult of drug Diversion . Nursing leaders must consider legal, regulatory, ethical,humanistic, and practical considerations in resolving this are the Nurse executive (NE)of a small, rural, critical care accesshospital in northeast WashingtonState.

2 Over the past 3 months, thenarcotics records from labor anddelivery area have not reconciled4 times. Specifically, the recordshave documented a total of six5-mg vials of fentanyl (ULTIVA)missing. Despiteexhaustiveinves-tigation by the charge Nurse andnurse manager, no one has beenable to locate the missing medi-cation or develop a fact-based logi-cal explanation ofwhat nurses on the unit suspectthat either the pharmacy sent boxeswith missing vials that or the peri-operative crew, who are in the ad-jacent wing, borrowed the vialsand failed to document their pharmacy is suspicious thatthe drugs have been diverted.

3 Thenarcotics locker is a manual systemaccessed by 2 keys. The narcoticslog is also a manual process, wherenurses document the administra-tion of narcotics and then performanarcoticcountforreconciliationat the end of the shift. (Receivedfrom C. Hollenback s Nexus paperfrom Gonzaga University s Depart-ment of Nursing , August 4, 2010.)JONA S Healthcare Law, Ethics, and Regulation / Volume 13, Number 1 / CopyrightB2011 Wolters Kluwer Health | Lippincott Williams & WilkinsJONA S Healthcare Law, Ethics, and Regulation / Volume 13, Number 1 / January March 201113 Author Affiliation: Department of VeteransAffairs Hospital of San Diego, : Hazel Y.

4 Tanga, MSN, RN,CEN, MICN, 3351 La Jolla Village Dr, La Jolla,CA 92161 Drug Diversion andNursing leaders ResponsibilitiesLegal, Regulatory, Ethical, Humanistic,and Practical ConsiderationsHazel Y. Tanga, MSN, RN, CEN, MICNC opyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is Ingalls: A Stellar Nurse Witha Hidden ProblemMaryanne Ingalls is the relief charge Nurse for the laborand delivery unit. She is the most highly respected,clinically expert Nurse in the department and has beenwith the hospital for 4 years.

5 She is often willing to pickup extra shifts and help out with the frequent staffingcrises faced by the hospital, given its situation of beingunable to hire staff for 2 vacant full-time positions. Shehas just left the office after confessing that she haddiverted the medication and stating she is entering aninpatient treatment facility tomorrow, specifically de-signed for healthcare professionals. She has requestedthis information be not shared with anyone, and she hasbegged to be allowed to return to her position once shehas successfully completed the program.

6 She says shewill be willing to submit to random urine screens on herreturn. What should the Nurse manager and nurseexecutive s next course of action be?..Drug Diversion : A Threat toPatients and HealthcareOrganizationsNurses who divert drugs pose significant threats topatient safety, but also become a liability to healthcareorganizations and the Nursing departments where thediversion occurred. Healthcare and Nursing leaders havea responsibility to ensure security systems are in place toprevent Diversion and protect patients if Nursing impair-ment is suspected.

7 The American Nurses Association(ANA) has taken a stance on Nursing impairment anddefines professional impairment as a Nurse who is unableto meet the requirements of the professional Code ofEthics established by the ANA as a result of cognitive,interpersonal, or psychomotor skill dysfunction fromexcessive use of alcohol or fictitious scenarioof Maryanne Ingalls, a stellar charge Nurse at a labor anddelivery department in a hospital in Washington, details astereotypical Nurse culpable of drug Diversion . Ms Ingallsadmitted to diverting 5 vials of fentanyl, a powerful nar-cotic agent, for personal use and agreed to seek inpatientrehabilitation treatment for her problem.

8 Nursing leadershave an obligation to address legal, regulatory, ethical,humanistic, and practical considerations in resolving theissue, as well as to become cognizant of the symptoms ofchemical a legal perspective, Diversion of drugs is definedas the unlawful channeling of regulated pharmaceu-ticals, including the misuse of prescription of narcotic Diversion in a hospital organizationrequires full disclosure to senior officials within theorganization, including the pharmacy manager, compli-ance officer, and human resources personnel. Ms Ingalls srequest for confidentiality applies only to personnelwithout vested involvement in the thorough investigation of the drug Diversion mustoccur immediately to search for system failures.

9 In-volved patient records must be carefully examined forfalsification and omissions. The investigation wouldprovide the NE with ample evidence to evaluate ifMs Ingalls violated state Nurse practice acts and/orcommitted minor infractions or a felony offense. Thecommitment of a felony offense could lead to furtherdisciplinary actions by the state board of Nursing (BON),local, and/or federal authorities. Accurate and detaileddocumentation of the investigation is imperative. Doc-umentation must be objective and specific, but shouldbe confidential and revealed only to the reporting and disciplinary ac-tions are required in many states, and penalty and otherproceedings are dependent on the addition, the NE has a legal responsibility to in-vestigate if organization policies and procedures wereviolated.

10 If these were breached, further systems reviewwould be warranted to assess for flaws and deficienciesthat could have contributed to the Diversion . In this fic-titious scenario, the primary failing in the system was themanual narcotic dispensing system. This system created anopportunity for a Nurse to easily divert pharmaceuticalswithout proper accounting methods. After the completionof a thorough investigation, corrective actions must be en-acted to prevent future Diversion , if the NE fails to disclose this informationor resolve the problem, further legal quandaries couldresult the NE being accused of maleficence for failingto protect patients from a potentially unsafe Negligent supervision could be charged against theNE for failing to report an impaired Nurse who hasadmitted to narcotic NE has an ob-ligation to ensure nurses provide safe and prudentpatient care.