It's 11 o'clock at night — Do you know where your medications are?

Take steps to prevent employee and family theft of drugs

A hospice nurse in Colorado was arrested in July for using a patient's name to obtain pain medication. The nurse also was charged in November for using a physician's name along with patient names to forge prescriptions for more than 4,000 pain pills.

In Louisiana, the staff members of Agape Hospice in Minden, reported a family member this year for stealing liquid morphine that belonged to her mother-in-law, the hospice patient.

Dealing with employees and family members or friends of the patient who might divert medication from patients is a critical issue for all hospices, says Jane Garrett, RN, MHSA, director of consulting services for Weatherbee Resources, a hospice consulting firm in Hyannis, MA. Although many hospice programs have policies in place to identify and handle drug diversion, it is critical to keep staff members aware of the policies and the agency's intent to enforce them, Garrett says.

"Hospice employees have open access to narcotics, they work without direct supervision, and they experience a high level of work-related stress," she says. "The combination of all of these issues increases the risk of employees stealing drugs."

The first step to prevention of employee theft is thorough screening of all potential employees before they are hired, Garrett says. In addition to background checks and reference verifications, include drug testing as part of the pre-employment process, she says. "An agency should expect every potential employee to undergo a drug test before employment, and an agency should put in writing that employees can be required to take a drug test at any random point during employment," she explains. "Although most agencies won't request a drug test unless there are suspicions about an employee, every employee should understand that random tests are part of the condition of employment."

In addition to being prepared to identify employees who might be stealing drugs from patients, all staff members need to recognize the threat of the patient's family or friends stealing medication, says Debbie Williams, RN, CHPC, administrator at Agape Hospice in Minden, LA.

"We have strict protocols in place to count medications at each visit and to count and dispose of medications at the time of the patient's death," explains Williams. In the case of the family member stealing liquid morphine, the nurse was accounting for the medications after the patient died. "The daughter-in-law offered to get the liquid morphine for the nurse, but when the nurse followed her to the other room, she saw the daughter-in-law trying to pour the morphine from the medication bottle into another container," she says. "We've had family members steal medication in the past, but never directly in front of us."

Agape staff members are trained on the signs that might indicate medication diversion by family members or other people in the home, Williams says. "If a patient is using more pain medication than usual or if the patient is experiencing pain even though the medication appears to be used, it might indicate that the patient is not getting the medication," she says. "We only deliver two weeks of medication at a time, and we monitor the patient closely to be sure that he or she is comfortable."

In some cases, when the patient is competent to handle medications, a lockbox will be placed in the home for the medications, Williams adds. "The patient and the nurse have a key to box, but other family members, guests, or friends can't open it," she says.

Also, be sure that staff members know some of the techniques that can be used to steal medication so they can take steps to prevent family members from stealing, says Garrett. "Fentanyl patches are often used in hospice but most people don't realize that 28% to 44% of the medication is still in the patch after 72 hours, the typical amount of time that a patch is used before a new one is applied," she says. "Someone who wants to steal the medication can place the old patch on the patient, take the new patch and use a needle to withdraw the medication," Garrett says. Because there still is some medication left in the patch, the patient still may receive some benefit, making it hard for the nurse to recognize that an old patch is in place, she explains.

A simple way to ensure that fentanyl patches are not stolen, is to use a felt-tip marker to write the date and time of the patch's placement and initial it, suggests Garrett. "Just as a nurse should count remaining pills at every visit, the nurse should also check the patches," she adds. "These are all best practices that should be used for all patients, not just those for whom you suspect a family member stealing drugs," she says.

Be sure to train staff members, especially supervisory staff, on the signs and symptoms that an employee might be using drugs, says Garrett. "Inconsistent quality of work; absences without notice, especially after a weekend or other days off; and excessive number of mistakes are just a few of the signs of a problem," she says.

There are many reasons to make sure your hospice policies adequately address medication diversion, says Williams. Not only is it important from a liability standpoint, but also patient care is affected when patients don't get their medications, she points out. "Our priority is to make sure patients are comfortable and if they are not receiving their pain medications, we are not meeting our goal," Williams says.

Need More Information?

For more information about medication diversion, contact:

• Jane Garrett, RN, MHSA, Director of Consulting Services, Weatherbee Resources, 259 North St., Hyannis, MA 02601. Telephone: (866) 969-7124 or (508) 778-0008. Fax: (508) 778-8899. E-mail:

• Debbie Williams, RN, CHPC, Administrator, Agape Hospice, 805 Homer Road, Minden, LA 71055. Telephone: (877) 371-1140 or (318) 371-1140. Fax (318) 371-1142. E-mail: