By Maureen Burger, RN, MSN, CPHQ, CPPS, FACHE

May is an important month for nurses everywhere. May 12 is the anniversary of the birth of Florence Nightingale – The Lady and the Lamp. This past week May 6-12, 2016 we celebrated National Nurses Week. The American Nurses Association (ANA) has chosen to emphasize the nurse’s role in creating and maintaining a culture of safety in healthcare, noting that it “starts with YOU.”

The ANA defines a culture of safety as having core values and behaviors resulting from a collective and sustained commitment by organizational leadership, managers, and workers that emphasize safety over competing goals.[1] The ANA is asking nurses to think about ways they can work toward creating a culture of safety, not only for their patients but also their own safety. Typically, we think about topics such as safe staffing levels, workplace injuries, or violence in the workplace. What if we were to expand our thinking to consider drug diversion in healthcare, and how both individual and collective nursing behaviors could reduce the risk of harm to our patients and our colleagues?

As we progress from novice to expert in our nursing practice, we develop a number of individual approaches to managing our patients. We learn to anticipate our patients’ needs, including when they will need to be medicated for pain. We anticipate being busy and wanting to be able to meet each patient’s expectations for pain relief as quickly as possible. So what do we do? We remove narcotic pain medications from the automated dispensing cabinets (ADC) long before the patient assessment indicates that pain medication is needed. We plan so well that we pull pain meds before the post-operative patient is even out of surgery. We want to be ready, but in doing so we put ourselves and our patients at risk for harm.

Some common scenarios

  • Do you sometimes “hide” your patients’ narcotic pain meds in locked drawers in their rooms even though you know that everyone knows the code or the same key unlocks all the cupboards?
  • Have you ever used a Carpuject™ as a “skinny vial” and then left the unlabeled syringe in an unsecured location? Would you know if the syringe or vial had been tampered with?
  • If you have to waste an unused or partial dose of narcotics, do you waste immediately or do you wait until the end of the day and “batch” them? Our practices concerning wasting narcotics are highly variable and tend to be influenced by our work group, staffing, and practice settings. Unfortunately, this variability creates unnecessary access and opportunity for drug diversion.

Trust is not a Strategy

We want to trust the people we work with; they have our back and we have theirs. But trust is not a good foundation to prevent and detect drug diversion. In my practice as a consultant, I have seen RNs using strange workarounds to witness narcotic waste, even asking one nurse to visually witness the waste and a different RN document the waste. A simple Google search will reveal numerous nursing blog threads describing different ways nurses witness and waste narcotics. Partial doses and witnessing is a burden. But what if we followed the guidance from the ANA and used our voices to advocate and collaborate with our pharmacy colleagues to reduce the need for narcotic waste? Less waste would make it safer for patients and nurses. Let’s explore some of the root causes for wasting.

Reducing Narcotic Waste

It starts with the physician order for the narcotic. Our physician colleagues trust us to make a judgment about the dose of narcotic for the patient, so they give us an order with a dose range. When a broad dose range is written (Morphine 1-10 mg IV), it creates an opportunity for the nurse to remove the 10 mg product form and administer a smaller dose to the patient, which creates waste. Some pharmacy information systems are built so that the nurse is required to remove the 10 mg product form because of the broad dose range order. So even if one wanted to give the patient 2 mg, the nurse must remove a 10 mg dose, which creates waste. Some hospitals restrict the product forms that are stocked in the ADC, which creates another need to waste. As nursing advocates, we should be working together with physicians and pharmacists to ensure that narcotic dose ranges are appropriate for the patient and enable the nurse to use the most appropriate product form. Pharmacy needs to hear from nurses to know how the products that are stocked in the ADC are being used and work together with a common goal to reduce access and opportunity for diversion via wasted narcotics.

Situational Awareness 

One important characteristic of a culture of safety is creating an environment where we can learn from each other’s errors and proactively detect and mitigate systemic weaknesses. Learning about drug diversion in healthcare is an important strategy to build situational awareness. Situational awareness is simply the ability to identify, process, and comprehend the critical elements of information about what is happening around you. The policies and procedures at our hospitals are designed to act as systems of checks and balances to help reduce the risk of harm to patients and staff from drug diversion. When we see deviations from the norm, this should be an alert that all may not be well. If you see something, say something. Use the chain of command to share your concerns. An impaired colleague is not a safe co-worker and is one who needs help. Consider how we can individually and collectively work to improve safety in the workplace by preventing and detecting drug diversion.

[1] Creating a culture of safety. Accessed May 10, 2016.



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