"Red Flags" of Drug Diversion

[WriteStuff]

Listmates,

My post is intended as a way of "helping" us in our work settings to possibly identify a peer or colleague who might be actively diverting drugs. None of us wants to "rush to judgement" on such a critical issue as this. To accuse or even "suspect" wrongfully is a very hurtful place to go for everyone involved.

However, the reality is that our working environment is inherent with accessibility, and availability of addictive drugs that can become a source of temptation for the Nurse who is battling her own demons of addiction.

The "list" of red flags I am proposing is in no way all-inclusive. However, I submit such a "list" from my own experiences as the once impaired Nurse that I was, with the hope that if you see such similar red flags, they are "signals" that might not be ignored.

As Managers, Charge Nurses, and Teammates we never want to "believe the worst" about our colleagues. Addiction is addiction, whether it's played out on the street corner, or within our medical settings, and within our medical settings we find it far more difficult to "believe" this could actually be happening, but it does.

I also submit this information with the hope that, if you suspect a colleague has a problem with addiction, you might find the courage to take the necessary, and proper steps toward intercepting the diversion for him/her, because left unchecked , he/she is not only compromising the safety of patients, but contributing to the progression of the disease. By "intercepting" I simply mean reporting your observations, concerns to the person you believe will be able to help.

This list is not necessarily in any particular "order" of importance, it reflects behaviors that potentially portray an underlying problem, when seen on a consistent basis:

1. Volunteers, frequently, to work overtime, extra days.

2. Uniform consists of a lab coat with pockets or clothing that is loose fitting.

3. Often "disappears" from the unit aside from expected "break times" (meals, etc.)

4. "Nods off" at the desk, or frequently c/o "feeling so tired" lately.

5. Mood changes from quiet and subdued, to suddenly being animated, charming, engaging and confident.

6. Avoids being in the Med Room when others are there, and is observed being alone much of the time (in the Med Room).

7. When alone in the Med Room, and others enter, makes a hastey exit.

8. Often "forgets" to sign out scheduled drugs until the end of the shift.

9. Volunteers to be the one to "make out new narcotic sheets" for oncoming shift.

10. Volunteers to be the one doing the Narcotic Sheet count, as opposed to the cupboard's Narcotic Stock supply at change of shift.

11. Volunteers to give your "prns" for you.

12. Volunteers to go to Nurse's Lounge and make the coffee whenever needed.

13. Has a locker assigned, but rarely uses it.

14. Often has "bruises" on top of hands, and covers them with a bandaid.

15. Appearance of bloodstain (fresh) on uniform pants in thigh area.

16. Her patients who are in pain "never seem to obtain effective relief", or are "still agitated, uncomfortable and anxious" when she claims she has "just medicated" them.

17. Shops for orders for her patients relative to pain medication. i.e., "Dr. So-and-so....the Vicodin is not working for Mr/Ms "X", could we give something stronger" - when the Vicodin had been working all along.

18. Charting reflects having "given" a narcotic injection to a patient on the day of discharge.

19. Writes a T.O. order for narcotics, but never called a doctor.

20. Volunteers to be assigned the sickest patient or patients. (who have narcotic orders in abundance)

21. Frequently leaves out details required on Narcotic Sheets.

22. Is often late to work.

23. Calls in sick more than usual.

24. Ignores, even "jokes" about the necessity of and seriousness of policy and procedure surrounding narcotic dispension and documentation.

25. Pockets multi-dose vials of normal saline (10cc and 30cc).

26. Has a "ready supply" of syringes and needles in her uniform pockets.

27. Is known to never "empty" out pockets of such supplies at end of shift and before leaving the hospital.

28. Gives conflicting information about her patient's degree of pain to oncoming shift. (on "her" shift, the patient was in "great" pain and "needed" medicating either more often, or with larger doses)

29. "Forgets" to tell oncoming shift she "just" medicated patient with a narcotic, and conveniently "forgets" to chart same on med sheet.

30. Is known to "save" partial doses of narcotics (not used), because...."patient might need it later."

31. "Wastes" narcotics without a second witness, and asks you to "please sign" at end of shift - "I was in too much of a hurry and no one was around then."

32. Distances self from management, administration, and others in charge.

33. Rarely asks "for help" from peers with regard to patient cares requiring such help. (prefers to "work alone")

This is an example of what might be observed in behaviors. There are many more I'm sure. I cannot stress enough that delicate place of not rushing to judgement, but at the same time relying on your common sense, caring concern and what your heart and gut might be telling you. If you find yourself in such a position, the better thing to do is take your concerns to even one person you trust, who will know how best to address your suspicions. You have the right and need to express your worries over such serious matters in the work place. An impaired Nurse on duty places her teammates in a very uncomfortable, and compromising position. When handled properly, the outcome for the Nurse, colleagues and patients, can be positive rather than tragic.

Good Management knows the risks that are involved when an intervention is necessary, and should be prepared to deal with the risks. (one being suicide)

I hope this is helpful information. Over a period of three years, I exhibited all of those behaviors, and toward the end, I was screaming (internally) to those around me......."don't you see what I'm doing, please, please stop me; someone help me!" And they finally did, before I could take my own life.

Thanks for "listening."

Bonnie Creighton,RN, MHCA

Mental Health Consumer Advocate

[jschut, BSN, RN]

Wow... I never realized... is it really that bad? I mean, is nursing a prime place for people to become addicts?

Julie

[WriteStuff]

Julie,

In response to your reply.......in reality, the Nurse in our worksettings, who crosses the line, and begins to divert drugs for her own use, has been moving through progressive stages of the disease of addiction (chemical dependency), long before s/he ever begins to divert.

In other words, the answer would be...."no", it is not BECAUSE OF our work setting that Nurses divert addictive drugs. The dis-ease of addiction is far more complicated than "temptation" alone.

In my personal situation, I came into adulthood with poorly developed skills for "doing life" so to speak. I was raised in a family environment that fostered dynamics of co-dependency, closed communication, and invalidation of genuine human feelings and emotions. My self-esteem and self-identity was under-developed and I had very poor "coping" skills to negotiate my way through the stressful events life brings our way. I also know today, which I had no way of understanding then, that I suffered from a diagnosable depression for which I never received treatment. When I reached the legal age for drinking, I did just that, and alcohol immediately "changed" the way I felt........it "reversed" the painful place I lived in (internally). It not only "numbed" the mental and emotional pain I lived in, but it gave a sense of "self-confidence" lack of inhibition, false sense of "courage", etc. etc. Alcohol, for me, in the beginning became my "solution", and was not a "problem."

It was only after years of resorting to my new found "solution" with alcohol, to "relieve" my pain, that not only was MORE required, eventually even MORE no longer worked. I was ignorant as well, that the underlying depression I had was progressively becoming worse. Alcohol is a depressant. I was self-medicating my depression with a depressant!!! My judgement became impaired, my thinking was faulty, and I was mentally ill.

The "idea" that it would be "ok" for me to "try" some of these narcotics did not present itself as an irresistable temptation, or something I couldn't "squelch." My thinking was so distorted by then, that the "idea" was "acceptable" to me, and I acted upon it.

But my point is, for Nurses who are diverting drugs in their work settings, a whole lot has undoubtedly been going on with them (internally, at mental and emotional levels), for many years, prior to the beginning of diversion activities.

Does this make sense to you at all? I hope it helps answer your question. Part of the dis-ease of addiction is ones loss of normal boundaries of moral and ethical behaviors that governs all of us.

I'm glad you asked the question. It is a good one.

Bonnie Creighton,RN, MHCA

Mental Health Consumer Advocate

[bagladyrn, RN]

Bonnie- Thank you so much for sharing your perspective and experience. I feel this is very brave of you to do so, and hope (know) this will be of help to other nurses. I have been on the other side of this issue, trying, with several coworkers, to convince administration to take action when a coworker exhibited almost every one of the signs you listed, as well as others such as long sleeves at all times and glancing references to her past alcohol addiction. Administration trying to avoid an "uncomfortable" situation, first denied the possibility, after all, "No one saw her shooting up" , then allowed her, encouraged her to quit without offering a diversion program. She lost her nursing license at her next job for the same thing. I am still angry about this years later, as I feel she was denied the chance she needed and was really asking for.

[P_RN, ADN, RN]

This is excellent!

May I add that diversion is not always Sched. II and III.

We had several instances of Ultram diversion which (until recently) was a nonformulary drug and was obtained from an out of facility pharmacy.

"Strangely" the whole bottle would be "mislaid" or since it was not a couted med...the number of tablets would not correspond to the number of doses.

We also had Toradol thefts. We had in the past before the Pyxis, Elavil, Valium etc be "lost." Ooops it fell under the refrigerator...etc.

I have been around people I never would have imagined who did, and around people I suspected who either left or management refused to investigate.

P

[oramar]

One person I worked with got caught because they were helping themselves to drugs that patients brought with to the hospital. Remember, 10 years ago we used to lock the drugs up that people brought to hospital with them? Well that provided an opportunity that was soon exploited. That is why we make patients send them home with family now.

[SuesquatchRN, BSN, RN]

So how do you fake it during the shift change count? Isn't that enough?

I can't go home without counting controlled substances with the oncoming hurse. And we'd batter tally, right down to a quarter milligram Ativan.

[TazziRN, RN]

Sue, you can't fake it at count time. The count will often be right anyway. We divert by taking under a pt's name and the pt either only gets a partial dose, or no dose at all. When the latter happens the pt often didn't even need it, hence the flag about the pt being in severe pain for the diverting nurse when the same pt seems comfortable with other staff.

I need to add that many of the signs on this list can be normal behaviors!!!!! I know people who volunteered for OT as often as possible for the extra spending money. I was eyeballed for going to the bathroom frequently, but it was never taken into account that I would bring a gallon container of iced tea with me.....what goes in must eventually come out! I also knew people who were late so often that if they'd arrived to work on time, then I would have been suspicious!!

My point is, when you see the signs on this list, watch carefully before you decide to report this nurse. Unless, of course, the signs include the blood spots on the pants, followed by extreme drowsiness! Also, keep in mind that there are many diverters who don't/didn't touch the injectables......strictly POs for me.

[ohmeowzer RN, RN]

we had this nurse that was found passed out the bathroom with a demerol syringe in her hand. then we had another one who actually had a Heplock under her shirt and was caught shooting up in a pt's bathroom. neddless to say they no longer have licneses... you work so hard for your license .. why do such stupid things.. idiots.....

[EmmaG, RN]

One person I worked with got caught because they were helping themselves to drugs that patients brought with to the hospital. Remember, 10 years ago we used to lock the drugs up that people brought to hospital with them? Well that provided an opportunity that was soon exploited. That is why we make patients send them home with family now.

We did that too, but then we had family members who would bring the meds back (or never take them home in the first place) so that their loved one could partake while they were in the hospital...

Our policy was to send all home meds to the pharmacy, where they were counted and ID'd and locked up until the patient went home (much like locking up their valuables).

[tntrn, ASN, RN]

I would to this list: a nurse who befriends, in a best friend way, a number of physicians, who then supply her with written prescriptions for whatever she might need, based on whatever story she might tell them.

[CritterLover, BSN, RN]

so how do you fake it during the shift change count? isn't that enough?

i can't go home without counting controlled substances with the oncoming hurse. and we'd batter tally, right down to a quarter milligram ativan.

if you know what the count should be, and are the one "counting," then you tell the person that is writing what should be there instead of what is there.

[color=#483d8b]if you are the one writing, then you write down whatever number should be there, regardless of what the "counting" person tells you.

[color=#483d8b]of course, all of this assumes that the second person isn't paying attention to what you are doing. often, that is the case: you are counting at shift change. one of you is tired and wants to go home, the other is trying to plan the day and get to work (and if you are like me, you haven't woken up yet).

[color=#483d8b]i used to work in a unit that still had a narc sheet. two of our nurses were diverting. we figured out that this is one of the ways they did it. i can still remember that manager saying "boy, i'll be happy when these narc counts start coming out right."