Drug Diversion Case Studies

The previous article on drug diversion explored the ways in which professionals in the nursing occupation respond to temptation by stealing medication from patients. This occurs when environmental security in a hospital, nursing home, or home health situation is not sufficient to detect and/or prevent this crime. Drug diversion is doubly dangerous because in some cases the patient suffers. The therapeutic value designed into the patients’ care plan is degraded severely by drug diversion.
Nurses who pocket or take medications cheat their patients of needed pharmaceuticals. But the nurses may also succumb to the near-universal lure of addictive pill-taking behaviors that impair their ability to think clearly and conduct their nursing activities responsibly. Opiate addiction is a global problem, and nursing can be a gateway career for addicts.
Drug diversion occurs when a nurse makes a decision to go against his or her better judgment. When this happens, day to day patient care is compromised. Since single-staff nursing plans don’t allow for auditing, the problem of pilfered medications will get much worse before it gets any better. Detection is the first method of arresting drug diversion. Symptoms of missed medications may blend with the patient’s pain spikes or be termed mood swings by distracted nursing staff.
Patients who vocalize extra pain or think that the nurse missed a pill may be disregarded.
Nurses who practice drug diversion may be in a position to target patients that nurses dislike and have no sympathy for. It may be some time before patient complaints are heeded and med counts correlated. And many nurses may move on before any official action can be taken.
Official complaints are the second step to take action against suspected drug diversion. Yet an official investigation by state or local nursing agencies is cumbersome and time consuming. And nursing homes go to great lengths to cover up their internal problems. When faced with legal liabilities a hospital may nullify patient lab reports or other evidence the patient’s care was impaired.
In instances when drug diversion takes place in home health scenarios, the abuse may never be discovered. The privacy and isolation of a home health environment are ideal elements for a nurse planning drug diversion. In any case, the patient will suffer. And the family members may never know why the patient is struggling for relief.
The third method to control drug diversion is peer policing. Nurses must take a stand from inside their community to cite and counsel nurses guilty of this crime. Leaders on every nursing staff should set an example of how to intervene and/or report drug diversion suspicions. Nurses who witness palmed medications should document what they see, and report the incident to the human resources director or the State Nursing Board. Anonymous complaints are allowed.
The most likely medication targeted by nurses for drug diversion is narcotics, painkillers, and opioids. These medications can alter mood and hinder feeling “down” effectively. Nurses practicing drug diversion are in fact trying to medicate themselves.
These pharmaceuticals are not only targeted for personal use. Drugs like Fentanyl, Dilaudid, Vicodin, Morphine, and others are highly marketable among addicts. Nurses may use pilfered drugs as currency among junkies with access to illegal street drugs. When a nurse is desperate enough for cash, students looking to maintain a high grade point average are good cash customers for diverted drugs. Students who reject shady contacts and promote a drug-free persona can utilize their nurse contact on the sly for ‘lifestyle enhancements’.
Case Study #1
Valery Gomez is an LVN working 4 days a week at a metropolitan hospital with high patient turnover. Valery started working six months and ago nursing is her first job. Her husband prefers her to have weekends off and her two children are taken care of on the days she works by her husband’s mother and family. Valery Gomez usually works the morning day shift.
Although initially Valery is bright, funny, and congenial, lately her personality when dealing with patients has changed. After twelve months on the job her nursing skills have not improved. Among the nurses hired in tandem with her, most have risen to supervisor or specialized posts. Valery’s peers have graduated to more complex work responsibilities,
It has been observed by the nurses on staff that Valery is often ” sitting doing nothing” and shoulders little of the actual individual tasks requied of desk nurses, and her charting and case load is usually poor or unfinished.
Lately several incidents with patients and Valery have brought unwelcome scrutiny to her employer from the County Health Department. The Ombudsman has received complaints about problems with Valery’s patient, problems that remain unresolved despite past counseling. Valery shows no remorse for causing great difficulty for other nurses and extreme physical stress to some of her patients.
Valery rarely lends a hand to any other nurses. She exhibits fits of temper when meds are requested and denys patients their needed painkillers without explanation. Valery makes a practice of hanging around the desk when the med-cart is adjacent and unattended. Valery recently has requested changes to her work assignments to shifts where the majority of staff wre gone.
While Valery made comments initially that she prefers a schedule with weekends free, now Valery has requested work on Saturday and Sunday. This is when most of the staff are gone. One of the patients, Nancy Lee, remarks that in private conversation Valery always told her that Valery’s husband wants her free on the weekends to entertain and care for the children.
Nancy Lee is a patient who recieves very heavy pain medication for multiple conditions. Nancy Lee has documented painful needle sticks from Valery. The Nursing Director has counseled Valery about not delaying Nancy’s med pass routine unnecessarily. The D.O.N. has repeatedly received complaints of Valery denying Nancy Lee her needed medication.
Valery alone of the many med-pass nurses resists the instruction to inform Nancy Lee how many Fentanyl she has left on her pain management precription. Mancy Lee has made complaints to the State Nursing Board about the matter.The local authorities have substantiated Nancy’s complaints.
Nancy Lee is articulate, alert, and ambulatory. She notices that paperwork in her chart written by Valery is inaccurate and incrimminating documentation concerning incidents with Valery has been removed. Nancy Lee hears from other nurses that Valery has refused to chart for them on occasion and also has refused to cooperate with requests from other nurses to perform tasks for them while they do her work.
Nancy Lee steps outside her roomn one day and observes that Valery Gomez visits the trash room frequently. Since the housekeeping staff normally do this, Nancy wonders why Valery alone of all the nurses disappears from the nursing desk floor while on duty. In the past, when Valery was Nancy’s nurse strange pills would be found in the floor. Nancy wonders why Valery avoids the closed circuit camera view so often.
In the past, Nancy Lee has noticed that many of the CNA staff hide in the supply room or the trash room and text to friends, play video games, or talk and use their cellphones. Nancy feels strobgly that Valery Gomez has been pilfering and experimenting with pain medications intended for the patients.
Nancy feels that Valery watches for opportunities to steal, hide, and ingest patient medication while on the job. Nancy has noticed that
Valery has lost weight and taken an interest in a handsome young nurse new to the facility. Nancy sees Valery drift through the weekend avoiding family responsibilities.
Suddenly it is found and told to Nancy that repeated impropriety concerning her pain medication has caused the med cart run out many months in a row. The pharmacy cannot account for the errors.

Nancy wants the D.O. N. to order a drug test for Valery after a weekend where the nurse repeatedly goes into the trash closet. Nancy sees Valery glaze over while another nurse is calling her name. Nancy sees a pill hit the ground after Valery comes out of the trash closet. When the good looking male nurse calls in sick, Nancy notices that Valery loses all interest in her work, snapping at peopke and gruffly answering the phone.
Does Nancy have the right to do this? How should the D.O.N. respond? How should the other nurses at the facility act at this time? Who should act, what should they do, and when does this become an investigative problem for police? How do the three methods to limit drug diversion, as outlined above, operate here?
Case Study #2
In a large hospital near Los Angeles, one of the patients in the SNF Alice. has noticed something disturbing. In the morning at 5:45 a.m. every day moans and screams start rising from the patients in the other rooms. The nurses tell this patient that many of the other patients are addicts who start yelling for their opiates and pain drugs too early. The nurses say that if they start giving out the pain medication for other patients too early, the next day the same thing will happen again and the patients will use up all their pain medication too early. The patient observes that there are no general administrator on duty at this time of the day.
After three months,the same thing happens very day. The patient notices how the exact same staff work the 11 to 7 a.m. shift daily even though alternates regularly appear on the other two shifts. Alice notices the call lights and alarm sounds series at this time, unlike at any other time, are often allowed to build and be ignored. The charge nurse responsibilities are shared beteeen a close knit group of nurses.
Soon the patient believes that the hospital does not know anything about how bad this problem seems. After months of different patients coming in and out the sane phenomena occur. On the day and afternoon shift the moans and screams do not recur as they during the “dawn patrol”.

Over time the patient fears that the hospital has suppressed recording this issue. Alice thinks that these SNF patients acting in this manner and reporting pain is being concealed and not documented so that their staffng acuity will not shift. This appears to be a cost cutting measure administered when no officials, visitors, or ancillary hospital staff can witness the outcry at dawn.

What questions should the hospital adminstrators be asking about why so many patients in the SNF are demonstrating this scale of pain indicators without a investigation or compassionate care response? What responsibilities does the facility have to monitor quality of care?

Drug Diversion in Nursing

One of the most serious challenges in the occupation of nursing is resisting the lure of addiction. But with the sheer availability of narcotics and opiods in nursing occupations, it is the casual use of pilfered ( and very strong,) pharmaceuticals that can springboard casual abuse into an unhealthy drug habit. Mood elevation and stress relief by the pill method can begin a nurse’s journay to drug dependency.
In the dark bolgia of drug addiction, factors such as affording drugs and the need to go to work can often prevent an overdose in the making. But in the case of career nurses, attendance, daily habits and the nursing lifestyle can feed a habit. Nurse may see evidence that another nurse is stealing meda, and using patient medications, without understanding what these behaviors mean.
Other nurses may shrug off strange behavior and mood swings that occur while otheers aee them doing unsupervised med pass duty. Nurses may not realize that state discipline records for regulatory infractions will follow them around their entire career.
Ideally nurses are caught and disciplined by management for incidents of drug diversions. But where oversight is slack and cost-cutting eradicates supervision, some nurses will slide down a slippery slope. If a nurse commits one act of drug diversion anf getsv away with it, they are likely to do it again.
Usually the casual abuser or recreational user of drugs stops short of a worsening a habit through exhausting their resources. But all a nurse has to do to feed their habit is to go to work. This fact doesn’t even begin to be able to address the difficulties that drug diversion makes for the patient.
People might expect nurses to know better. But when the only thing between a nurse and a drug overdose is a thinly spread staff and an unlocked medicine cart, problems will occur. Sometimes the nurses doing the drug diversion are on too-friendly terms with the individuals doing the closed circuit camera scrutiny
And many nurses fall victim to addiction by the dint of by having immediate access to powerful and clinically addictive nedications. Because the world of nursing is suffused with tasks consisting of interactions handling drugs. The temptation is impossible to ignore.
Once a drug habit forms, superhuman strength can’t make it stop
And nurses are only human.
About 80% of theft in retail or service professions is estimated to be internal. As value-based medical service models replace community benefit models, facilities that dispense drugs to patients become part of those crime statistics.
While police officers do not patrol nursing corridors and hospital wards, the goods are much more stringently restricted than folded sweaters or designer handbags. Electronic handprints and punch codes for med cart access cannot eliminate instances of drug diversion. Rather, unsupervised access to schedule one and two drugs such as narcotics enables any nurse to abuse their pharmaceutical access. Each nurse can elect not to exercise discretion in palming this or that pill or stealing an unwanted drug dosage.
Technical specifications and licensed nurse training are designed to prevent the mishandling of drugs and pills. But medications in the dosage sizes given to patients are usually a tiny pill or two. These are so small that drug diversion is not physically difficult. Such pills can be concealed in the mouth, hand, fingers, pocket, or even a hairband or cellphone cover.
Many nurses feel insulated from the threat of detection or capture due to the small community or office space that nurses inhabit. Nurses who filch medication from patient dosages may feel that the presence of other nurses in a small staff or closed community discounts the risk of getting caught.
There is an old saying that “familiarity breeds contempt.” Familiarity with the nursing homr or hospital workplace may orient a nurse to oversight shortcomings. Daily nurse work can bring forth feelings of antagonism against patients and causr anger and aggression against the facility owners or operators.
The angle of security cameras and the known infrequency of the facility to review the security footage may encourage drug diversion. Also, in a facility where narcotic record keeping MAR fidelity is poor, certain nurses may exploit these circumstances to pilfer patient medications.
In the nursing world, theft of drugs from patient dosages is called “drug diversion”. This practice indicates by its name how nurses behave as if they are following routine med passes. Drug diversion usually occurs in a busy hospital or care facility where oversight responsibilties are routinely overlooked.
Three case studies below illustrate how nurses can exploit vulnerabilities in hospital and long term care facility. But it is not only medical institutions that must be wary for drug diversion. Home health nurses operate in an environment even more probable to experience drug diversiin. The isolation and probable unlikelihood of detection creates a temptation some nurses may not be able to resist.

The legal liabilities that any nurse opens themselves up to, when caught committing drug diversion, are significant. The legal problems such nurses may create for a hospital group or long term care facility management corporation may be career-ending lawsuits.
Not every nurse steals medication. Some nurses are so wary of falling prey to drug use and drug diversion temptations that they make sure to dispense medications under closed circuit cameras and in the presence of another person or a group of nurses. But drug addicts are prone to secrecy and stealth to support their habit.
The possibility is also very high that some nurses are using employment in long term care facilities as a means to skim narcotics from their routine pharmaceutical distribution. If a nurse has a predisposition to emotional problems, job stress, or drug addiction, they may seek out second-rate facilities where security and supervision are slight.
(see the following article for case studies in Drug Diversion).

Should You Be An E.R. Nurse?

An E. R. is a challenging and high pressure work environment that involves high stress and heavy patient turnover. But nurses coming up through the ranks should seriously appraise whether or not an Emergency Room is the proper career choice for them.
The hiring convention to screen candidates for professional nursing E. R. jobs is to hire from within. Or to hire nurses with commensurate nursing experience from Emergency Room or Urgent Care assignments elsewhere.
The hospital may depend on direct referrals for staffing its Emergency Room. There are some fast-track programs available. The hiring managers from a given hospital or Urgent Care clinic may want to review a student nurse’s transcript if they apply before graduation. If the compensation is particularly desirable, a second interview may be required after references and NCLEX test scores are reviewed.

All E. R. nurses do not operate in a real time work place at the same level. An E. R. can be a daily test of patience, nerves, and professionalism.. The skill sets for an E. R. nurse applicant should be above average in quality and the personality type of the nurse candidate adaptible. But those who can’t function in the fast-paced and demanding hospital or clinic E. R. should face facts about the suitability of their destination job title.
Of all the stressful career choices in the world, an Emergency Room nurse ranks directly behind police officer and firefighter. The Turn-and-burn mentality of many high volume E. R. facilities can wear out the freshness of a newly qualified nurse and age them prematurely.
Some nurses stay in this line of work out of feelings of dedication and trying to make a difference in the world. All too often, such nurses experience stress snd occupational burnout.
Also, the associated risks of depression, addiction, and alcohol and drug abuse for nurses working in the Emergency Room is far higher than the more sedate clinic or the long term care facility nursing pace. The work in an Emergency Room by nature does not absorb nursing errors and the consequences of nursing carelessness can be disastrous.
E. R. employers are not as forgiving of mistakes as normal-pace-type nursing employers might be. Patients in an E. R. setting present a challenge to any nurse lacking in “people skills”. Nurses must often deliver very difficult news to individuals or groups of people already crippled by lack of a family or support system.
Emergency Room nurses put in almost double the performance intensity of clinic desk nurses or long term care med pass nurses. The hours can be brutal and the schedules can make home and family commitments impossible. Physicians will demand near-perfect nursing performance from E. R. nurses at all times. No matter how fatigued or overworked the nurse is, he or she will be required to have a seamlessly professional attitude, critical thinking skills, and alert demeanor.
An E.R. nurse is the Gold standard” if nursing. More than any other kind of nurse, except the Home Health nurse, an Emergency Room nurse is the ambassador for the entire occupational body of nurses worldwide. Patients new to the world of medical care will see more interaction with E. R. nurses than with any other provider personnel.
Student nurses aiming for Emergency Room tenure need to honestly evaluate their skills. Performance in practicals skill development and internships will yield qualified feedback. The unpredictability of the E.R. work environment demands heightened nursing skills, quick thinking, and stamina.
If the feedback a newly qualified nurse gets from their nursing school professors, supervisors and peers falls short of the mark, nurse candidates should rethink applying for work in an Urgent Care setting. Student nurses browsing their career choices should review their strengths and weaknesses when selecting their occupational nursing career environment. Career counselors can answer further questions along these lines.

Intra Venuous Therapy

Nurses from time to time will be required to perform tasks that demand mastery of a technical equipment procedure. To deliver a programmed regimen of medication, when a patient is a hard stick, to prevent repeated needle stick trauma and injuries to the epidermis, an intra venuous line is used. The vein inside the hand or arm is located and mapped.
An ideal site for connection of the vein to the external delivery device is located. This is where the vein will be connected to an attached ( or hung) intra-venuous line. Thus liquid medication can be set up to line-drip into the body via a plastic catheter.
After this site is located, the first attempt is executed. The procedure to install the exterior I.V. (catheter) is begun by setting up surgical drapes for infection control. Masks, gowns, and gloves should be worn. The internal vein location is sited on-screen using live EKG or radiographic video photography. This internal site is evaluated for positive and consistent blood flow and the successful circulation of the medication.
This attribute of vein quality is needed for best distribution of the treatment material throughout the corpus. If the ideal site cannot be mapped, the procedure should be rescheduled.
The vein physically is reached via needle treated with Lidocaine. After a few moments a burn and a mild pain will be felt. Pre-medication against patient discomfort should be anticipated. The catheter ligation is then performed. If the venal connection is not successful a repeated attempt may be made as long as site integrity is maintained. The ultimate site must be clean and free from lesions or irritation.
The catheterization must now take place. Usually I.V. lines are put in during in-patient visits to or in a hospital radiography lab. But specialty nurses are now licensed to do this as part of a mobile health services arrangement. The plan of care adapts to include I.V. therapy.
After images of the vein assist the surgeon, nurse, or technician in mapping the best external route from a vein, then the vein is connected to the epidermis via an exterior cannula and channels of plastic or vinyl tubing. The patient may require a PICC line, a Heplock, or a formal intra venuous line catherization.
The infusion of catheterization for Hep lock, I.V., and PICC line devices requires formal technical training. Physicians and other providers learn the I.V. technique, sterile procedure etiquette, and the immediate I.V. environmental infection control. The administration of an I.V. and the facility policies must be followed to the letter for site hygiene, optimum infection control, and medical treatment etiquette.
I.V. administration is a critical nursing skill that can save many lives.
. Focus on anatomy and needle stick skill sets is critical. Student nurses should petition for radiography internships if they are interested in I.V. catheterization as a career.
The site injection procedure is done via E.K.G. placement or radiology X-ray. Siting should be done by a nurse that knows or has become familiar with the patient.
The efficient I V. nurse will appraise how infusions will alter the patient’s daily routine. Minute details can affect placement success. Discussion of the patient’s daily routine is essential.
Will the patient eat before or after the medication? Will the rolling I.V. rack allow for bathroom access? Which arm or hand is best for the siting? How dies the patient sleep? Viability of the overall catherization effort for intra venuous infusion must be evaluated with respect to specific patients.
How old is the patient? How well can they manage to sit and be still and maintain drip flow? Have they managed an I.V. before? Are they in a skilled nursing or long term care facility? Do they thrash around uncontrollably during slumber? Patients can do damage to themselves or the I.V. line while moving during sleep.
Do they take a sleeping pill at night that limits control of the arm with the I.V. in it? How alert and ambulatory is the patient?Exploring these issues can ward off problems necessitating repeating the procedure. Conversation with the patient and issuing verbal prompts during the procedure can help I.V. line patients feel more in control.
All these factors can play a major role in the successful siting of an intra venous catheter device.
The epidermis is very sensitive to the strong adhesives used in the catheter site securement. Nurses should be careful not to strip the skin at the site. Attention should be paid to any allergies or past problems with bandages, metals, or tape. If the adhesives used in the I.V. siting cause an irritation, the dressing can come loose, the skin can over-adhere, or a site lesion cause an infection to spring from access to the vein.

Before scheduling the I.V. procedure, the patient’s chart and medical history must be reviewed. Sensitivity to the prescribed medication and success with previous regimens if intra venuous therapy should be evaluated. Upon efficient administration of a midline catheter or intravenuous line, repeated inspection and evaluation of the site should ensue. Then caretaking literature should be available for distribution, to the chart or to patient or resident.
If the veins have become occluded or blocked, the effort to site the catheter may need to be redone. The cost of these procedures to be repeated may be oppressive, not to mention the inconvenience, expense, and interruption of the ordered I.V. treatment.
There is some debate as to whether or not EKG or radiography siting procedure is preferable at the commencement of the ligation order. Hospital or facility policy must govern whether or not mobile services can be used in place of stationary institutional surgery centers. Specialty licensed and specially qualified nurses and technical personnel must be staffed for all of the above procedures.
Nurses should constantly monitor the catheter midline site for redness, stiffness, swelling and unusual pressure around the line-in. Remove and re-apply the sterile dressing as needed. Prevent loss of sterile I.V. conditions by using iodine or alcohol to clean residues or backflow from the insertion lesion.
When changing the adhesive tapes and cleaning the I.V. site cap, inspect the site area for unconventional blood spotting, movement of the line too far in or out of the I.V. site, or stained or fouled adhesive material next to the skin.
Always make sure to wash the hands in warm soapy water before contact with the site area and dressing materials. Allow adequate time for refrigerated material to come to room temperature. Check tags and labels upon fresh presentation of pharmaceuticals to the I.V stand, inside the patient room or clinic area.
Nurses and intra venuous medication administrators should always flush the line clean and make sure fouled tubing is removed from the site attachment immediately. Saline flushing schedules should be found on the patient’s chart or in the endorsement sheet. Counter signatures should reviewed for dressing and taping checks. I.D. tags and site condition checks should be conducted before the next I.V treatment.
Never flush against resistance. Review the infuaing catheter to adjust flow pressure. Advise the patient to notify nurses or caregivers to administrate prescribed anti-nausea medication if symptoms present.
Report unusually distressed wound sites to a charge nurse or physician for further instructions. Patients, nurses, and caregivers should be watchful for side effects throughout the duration of the I.V. administration. Upon successful completion of the I.V. treatment, nurses can refer back to the prescribing physician for further orders.

Nurse Training Issues

Nurses need to be trained to treat patients and all their needs, as required. Nurses cannot pick and choose which chores they need to do on which patient, nor do they get to arrange the timeframe that suits them best. Often a case load of needy patients means that the nurse will be juggling various needy patients as well as performing paperwork responsibilities, charting, and intaking new patients at the same time. Not to mention answering the phone and dealing with walk-in clients.

Nurses must be ready to say “yes” to every task. They may be reassigned to other wards or areas as needed. Nurses must groom their computer and Internet research skills to match today’s technological advances. There will be slow days and there will fast days, but nurses are responsible for treating all patients at the highest level of care no matter what their time limitations are.

For example, in a clinical care situation in training, a nurse might have to alter the setting on a EKG machine or test out various pharmaceutical applications on a patient to achieve the best result for lowered blood pressure. But the time and physical availability for results and communications in real time versus training environment may not match the situation reality. Phones on the ward training, another nurse needing help, or a new admission coming onto the scene may distract a nurse.

Nursing students have a training experience that is simple cases of ongoing treatment cases. but in reality medical care plans are much more complex. Patients may be resistant to treatment or not observant of dietary restrictions or their rest order as given by the physician. Nurses on the job often give qualified objections because they have not had a chance to speak with the doctor before issuing pain or treatment medications to a patient they have never seen before. Patents are likewise alarmed they are not seen or given a consultation before a dosage regiment is instituted.

Nurses are the key communicators in this scenario. Nurses in this instance carry more responsibility to review both the patient set of criteria and the data involved with possible side effects of a drug. They must weight this information against the patient’s benefit, versus the entire set of pharmaceuticals being introduced to the patent’s bloodstream. Often a nurse can spot a contraindication before anyone else, and the thrust is upon them to do so. Nurse must also counsel the patient and asses them psychologically at all time. When shifts change, nurses must convey both verbally and in writing the most timely changes in patient assessment to the next charge nurse. These must be done in accurate medical terminology in a transparent style.

Is the patient a physical threat to themselves or others? Is the effect of any change or restriction in medication or privileges affecting them negatively? Are they speaking to themselves or others in a manner that shows a change in self esteem or motivation to heal? Some patients may create incidences of panic disorder and need to be housed a negative ion chamber. A psychological evaluation referral is appropriate at this time. They may try to not take their medication, create obstacles to treatment, or become even more ill. Student nurse skills must adapt and grow to meet the situation.

It is hard to train a nurse for the variety of challenges and issues that come up for their patients in this kind of scenario. Occasionally physicians will be flexible and change to the individual care plan will be made. It is vital to the medical outcome that these circumstances be communicated to the next nurses and on-call physicians. Being able to perform simple tasks like recording dosages and medical administration while balancing management of multiple patients can get tricky.

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