Michael C. LaFerney

Later that day, the primary physician comes into the nursing home to check his patients. Johnson runs into him and remarks, “It must be a pain to be woken up in the middle of the night.” The doctor replies: “What are you referring to? I slept all night. No one called me.” Johnson checks the record, sees the telephone order on the medication sheet, and shows the physician, who insists he was never called. Did the patient receive the medication? When confronted by Johnson and the physician, the nurse who had written the note says she had been having difficulty sleeping and had faked the phone order to obtain Ativan to help her when she went off duty. 

What can nurse managers do?
Drug diversion is a growing problem in nursing. Nurses can use methods that are hard to detect. The incident described above was discovered by accident. What can be done to minimize theft of medications by nurses?

The nurse manager must be aware of not only diversion methods but also types of medications abused. The most common medications diverted are those that relieve pain and alter mood and consciousness—narcotics, benzodiazepines and stimulants. Other classes of medications must also be considered. Antipsychotics are not often thought of as a drug of abuse. Seroquel (quetiapine), for example, is an antipsychotic that aids sleep and, on the street, is purchased by addicts for this purpose.

Most nurses are not diverting medications to sell. They are stealing them to treat their own addictions. One study suggests that up to 20 percent of nurses have substance abuse issues. Another study suggests that the rate of some illegal drug use by nurses is lower than that of the general public, but that the use of prescription drugs is higher (Chait, 2008). The access nurses have to these drugs is the problem.

To address the drug diversion problem proactively in health care settings, committees should be formed. Periodically, charts should be reviewed specifically to look for diversion. If a PRN medication is given, a corresponding note should describe why it was given and if it was helpful to the patient. Physicians should sign all telephone orders for medications and include a specific time frame to verify they were given. This can be problematic in long-term care settings where physicians are not required to be physically present. Appointing someone to periodically call the physician to verify that phone-ordered medications were given will let nurses know that drug administration is being monitored. The nurse supervisor must be visible.

Since some nurses wait until the end of the shift to chart their meds, med carts should be checked and counts done in surprise “inspections.” Controlled substances should be recorded immediately. Nurses whose carts and counts are in order should be rewarded and praised. Drug diversion is a serious issue that can result in loss of license, criminal and legal charges, higher costs to the hospital and, most importantly, harm to the patient. While the seriousness of the issue must be emphasized, the process should be educative and non-punitive. Nurses should be encouraged to report drug errors, and nurses who voluntarily disclose they’ve been diverting drugs should be aided in seeking treatment.

In my chart reviews, I often see PRN medications that have not been used or have been used sparingly for months. Unneeded medications should be returned and discontinued. Patients who do not seem to respond to administered medication, especially pain medication, should be evaluated. If there is no logical reason for nonresponsiveness and the chart shows that one nurse is giving the medication, drug diversion should be considered. A nurse who administers PRN medication for pain or behaviors more frequently than other nurses should be monitored. The reasons nurses administer PRN medications for pain and behaviors are diverse (LaFerney, 2005), but educating nurses about alternative strategies may be very helpful in reducing PRN use.

Nurse managers need to know the signs and symptoms of an impaired nurse. They can include frequent sick time, lateness, poor job performance, excessive overtime use, excessive time in the medication room preparing meds, missing syringes, frequent reports of spilled medication and charting errors. Physical symptoms, which can include poor hygiene, fatigue, and cold-like symptoms such as a runny nose (a sign of withdrawal), and mood changes—apathy, irritability, energy bursts, confusion, etc.—may also indicate recent substance use.

In summary, drug diversion is a serious issue that results in excessive costs to the health care system, damaged careers, impaired health of nurses and, most importantly, neglect of and harm to people entrusted to our care. Proactive monitoring by nurse managers is essential, given the potential consequences for all involved. RNL