Take action now before drugs cause a tragedy at your facility

Recent incidents and study raise tough question: What can you do?

(Editor’s note: In this first part of a two-part series on drug-impaired employees, we give you suggestions on how to avoid employee theft of narcotics. In next month’s issue, we’ll discuss the characteristics of drug-impaired employees and give you resources for helping them.)

A medical student graduates from an anesthesiology training program, gets married, and wins a coveted position with a major medical center. Six months later, he’s found dead in a hospital restroom from an overdose of drugs taken from the operating room.1

A manager at a surgery center is indicted on charges of tampering with and illegally obtaining Demerol. The indictment charges that the manager, a licensed practical nurse, knew that the drug would be used in surgical procedures, but siphoned the drug from its containers and replaced it with a saline solution.2 He was caught when a pharmacist noticed that a physician’s signature on a Drug Enforcement Administration (DEA) order form didn’t appear authentic, according to the center’s administrator.

Last summer, an anesthesiology resident drove off a sea wall, built to prevent erosion by the sea, with an intravenous line inserted in his arm and several hospital-grade narcotics in his car. He was put on leave pending the outcome of an inpatient treatment program.1 Earlier this year, there were two accidental overdoses in Harris County, TX, within two months; one was a 34-year-old RN, and one was a 41-year-old anesthesiologist.1

Drug abuse cases involving outpatient surgery providers, particularly anesthesia providers, are not isolated. Experts point to the fact that anesthesia providers often have easy access to drugs. A survey by Duke University in Durham, NC, of 133 U.S. anesthesiology training programs found 1.6% of anesthesiology residents and 1% of anesthesiology faculty members abuse operating room drugs.3

"Anesthesia, as far as I know, is the only field in which accidental suicide is one of the hazards of our work," says Saundra Hudson, CRNA, peer assistance advisor for the Park Ridge, IL-based American Association of Nurse Anesthetists.

The recent reports of an indictment and fatal overdoses have raised troubling questions in same-day surgery settings across the country. How can managers prevent their employees from stealing drugs? And what can be done to detect and assist impaired employees? Consider these suggestions from experts in the field:

Watch employees closely.

Managers play a key role in preventing theft of drugs, says David Horvath, PhD, RN, CD, clinical services coordinator at National Health Care Associates in Lynbrook, NY, and president of the Blaine, WA-based Consortium of Behavioral Health Nurses and Associates.

One critical step is thorough background checks before hiring and feeling satisfied with answers on interviews for unexplained periods of unemployment, erratic job histories, etc., he says.

Other key steps include adequately supervising employees and maintaining good relationships with workers so they’ll tell you if something is wrong, Horvath says.

Keep in mind that addiction can happen to anyone, says Teri Kersting, administrator at the Kansas surgery center where the manager was arrested on Demerol charges. "It is usually someone you least expect," she adds.

If convicted, the manager faces a maximum sentence of 10 years in prison, without parole, for tampering with Demerol, and a maximum of four years for each of seven counts of illegally obtaining a controlled substance. He is no longer working for the center. The incident was reported in the media, but no patients called with concerns, Kersting reports. "We were very fortunate the way it all turned out," she says.

Educate yourselves and your staff on chemical dependency.

Learn as much about chemical dependency as possible, experts advise. Most importantly, understand that chemical dependency is a disease, Horvath says.

Art Zwerling, CRNA, MS, MSN, PA-C, FAAPM, program director of the Pennsylvania Hospital School of Nurse Anesthesia in Philadelphia, says, "People need to inservice their staffs about the incidents and regular occurrence of chemical dependability, accept is as an occupational risk that goes along with what they do, and recognize earlier signs and symptoms, so we don’t find colleagues dead with syringes in their arms in the call room." Zwerling is coordinator of Anesthetists in Recovery (AIR) and a member of the American Association of Nurse Anesthetists’ Peer Assistance Advisors Committee.

Track ineffective patient medication.

There may not be a discrepancy if staff are careful to document appropriately, Horvath warns. In that case, be alert to patients who report situations such as inadequate pain control, sleep problems despite prescriptions, and anxiety even though they have taken prescribed sedatives. "The staff may be giving them placebos or something else," he adds.

One recent disturbing trend is for staff or addicted relatives of patients to steal Duragesic fentanyl transdermal system patches (Janssen Pharmaceutica Products, Titusville, NJ) for time-released pain control off patients’ skin and put the patches on themselves, Horvath says.

Consider random drug testing.

Elna Jacks of Knoxville, TN, the mother of the anesthesiologist who died of an overdose, says she can never excuse the choices her son made. "[But] they drug screen in Wal-Mart, from the door greeters to the floor sweepers," she says. "A person who has your life in his hands is not drug tested? What does the medical system need to do so another beautiful person does not die for this reason?"1

In the Duke study, 61% of department chairs indicated that they would approve of random urine screens of anesthesia providers.3

"I personally believe that all anesthesia providers should be having random [urine drug screenings] given the risks," Zwerling says.

Kersting’s facility has not performed random drug testing in the past, she says. "This may be added to our policy and procedures in the future," Kersting says.

But the test is just one piece of information, emphasizes Connie C. Mele, MSN, RN, CS, CARN-AP, Mecklenburg County program administrator for substance abuse services in Charlotte, NC. "If employees test positive, they then should be referred to the company’s EAP [employee assistance program], or if the company does not have one, to a therapist in town who specializes in alcohol and drug problems for a thorough psychosocial assessment," Mele says.

If the employee is found to have an addiction, then proceed with treatment instead of firing the employee, she advises. "Addiction is an extremely treatable disease," Mele emphasizes.

Have strict accounting of narcotics.

Experts are quick to point out that outpatient surgery providers often have poor accountability of drugs, particularly with the waste of narcotics.

One lesson Kersting passes on to other managers: "Always be aware of staff, and have checks and balances in place for procedures on anything to do with the narcotics logs and counts."

Horvath advises spot checks.

Be on the alert for an amount of drugs requested that is disproportionate to the usual dosage and requests for unusual drugs with vague or bizarre explanations about their use, Zwerling adds.

"Particularly in perioperative services, anesthesia, PACU, and recovery, there should be a strict enforced policy including waste of narcotics — how they are signed out and handled," he says. "There needs to a shift-to-shift count, and there needs to be the ability to check waste by refractometry."

Tighter controls and limited access to narcotics are key, Hudson says. For example, in one surgery center, preoperative nurses were signing out drugs for anesthesia, but anesthesia providers could obtain drugs as well, "so there were drugs everywhere," she says.

Drugs shouldn’t be transferred between units, Hudson advises. Also, for facilities that have a pharmacy, send drugs back to the pharmacy to be wasted so that pharmacists can conduct random checks on syringes, she says.

Mele says, "The idea of sending drugs to the pharmacy to be wasted is one method to prevent nurses who have addiction problems from having access to those drugs. The precautionary factor is that there are some pharmacists who also have addiction problems."

Freestanding centers are particularly vulnerable to drug-impaired employees because staff members become so close and trust each other, Hudson warns. "It’s not OK, at the start of a case, to put a signature where the narcotics wastage is," she says. "You wait, even if it’s your brother."

Mele says, "I believe that the best preventative techniques are random reviews of narcotic sign-out sheets, looking for patterns of high usage and wastage by particular staff, patients who complain of not getting relief from their pain medication, and staff who have changed dramatically in the last several months in appearance, personality, and productivity."

Be watchful, and maintain that watchfulness, Hudson says. "It’s not doing anyone any favors to not be vigilant," she says.

Sources and Resource

HCPro of Marblehead, MA, is offering a 90-minute audioconference titled Drug Theft in Health Care: Real-World Strategies for Prevention and Regulatory Compliance, 1 p.m. Eastern time, June 18, 2003. The conference will include coverage of health care-specific regulations, laws, and accreditation standards relating to drug theft, as well as questions and answers. The cost is $234 for one phone line. To subscribe, call (800) 650-6787. The speakers are Donald Bogardus, author of Drug Diversion in Health Care: A Guide to Identification and Prevention, and Thomas Taylor, vice president and general counsel for Gundersen Lutheran, a health care network in La Crosse, WI.

For more on addressing addiction, contact:

• Saundra Hudson, CRNA, Peer Assistance Advisor, American Association of Nurse Anesthetists. Telephone: (502) 454-5671. E-mail: meetingmaker@bellsouth.net. Web: www.aana.com/peer/.

• David Horvath, PhD, RN, CD, Clinical Services Coordinator, National Health Care Associates, Lynbrook, NY; President, Consortium of Behavioral Health Nurses and Associates, Blaine, WA. E-mail: dbh1@optonline.net.

• Art Zwerling, CRNA, MS, MSN, PA-C, FAAPM, Program Director, Pennsylvania Hospital School of Nurse Anesthesia, Philadelphia; Coordinator, Anesthetists in Recovery; Member, American Association of Nurse Anesthetists Peer Assistance Advisors Committee. Web: www.aana.com/peer/. Telephone: (215) 829-5691. E-mail: a.to.z@comcast.net.

References

1. Hopper L. Overdose points to holes in system — Doctor’s death attributed to drugs stolen from operating room. Houston Chronicle, April 13, 2003. Accessed at HoustonChronicle.com.

2. U.S. Department of Justice, U.S. Attorney, District of Kansas. News Release; Grand Jury Returns Indictment. Wichita, KS; April 8, 2003.

3. Booth JV, Grossman D, Moore J, et al. Substance abuse among physicians: A survey of academic anesthesiology programs. Anesth Analg 2002; 95:1,024-1,030.