A sample policy/procedure for departments of anesthesia on chemical dependency

Note: This policy and set of procedures are provided as a sample and must be individualized to meet the specific needs of your work setting, take into account the nurse practice act of your state, and any pre-existing policy concerning chemical dependency (i.e., drug testing, pre-employment screening, employee assistance programs, etc.).


This facility (name) has a vital interest in maintaining a safe, healthy and efficient environment for its employees and patients, an environment free from the misuse of drugs and alcohol. Recognizing that chemical dependency is both a disease and a professional hazard, the purpose of this policy is to provide guidelines for the reduction, confrontation and management of substance abuse within the department of anesthesia.


It is the policy of the department to provide a safe, fair working environment for all anesthesia practitioners and their patients.


I. Education.

All members of the department will be informed about their risk of becoming chemically dependent, how to recognize impairment in the workplace, the importance of proper intervention, and how to assist those with a prior substance abuse history to (re)enter the department. Supervisory personnel will receive training on the conduct, behavior and indicators of drug and alcohol abuse. They will also be trained in the guidelines and administration of the department and institutional policies on chemical dependency. The department is responsible for conducting an education and training program, as well as providing information on related resources.

  1. A minimum of six educational hours specific to chemical dependency shall be provided each member of the department.
  2. Offerings will be provided by experts in the community, multimedia resources, and/or practitioners in recovery.

The department will maintain a resource file of:

1. The names, addresses and telephone numbers of community drug and alcohol counseling and rehabilitation programs.

2. Relevant educational materials from the state licensing bodies, and professional associations to include:

  1. Medical and Nurse Practice Acts relevant to impairment.
  2. State Peer Assistance Committees.
  3. Pertinent AANA and ASA resource publications/material on peer assistance.
  4. Information on the AANA Peer Assistance Hotline and the ASA Committee of Occupational Health and Safety will be prominently posted within the department.

3. Mental health providers and entities designed to assist employees with personal or behavioral problems.

II. Drug Testing.

Anesthesia providers shall be required to submit to drug testing as a condition of employment. Failure or refusal to cooperate with any aspect of this policy including, but not limited to, refusal to sign forms consenting to drug testing or the refusal to submit to urine or blood sampling for testing to determine use of, or impairment by, a controlled substance or intoxicant will result in disciplinary action up to and including discharge and the reporting of use to the appropriate authorities.

Applicants and employees will be required to sign an acknowledgment form and consent to this policy. An employee may be required to undergo a blood test or urinalysis under any of the following circumstances:

  1. When there is reason to believe in the opinion of this facility that an employee is under the influence of intoxicants, nonprescribed narcotics, hallucinogens, marijuana or other non-prescribed controlled substances.
  2. After the occurrence of a reported work-related injury/illness, or accident while on the facility property or during work hours.
  3. On a random basis.
  4. During any physical examination provided by the facility.
  5. When employees who have been on leave of absence, rehire after layoff, or who have not worked within the twelve weeks preceding their return date.

Testing Procedure — Drug testing will be conducted using the following measures.

  1. Employees will be required to sign the facility’s consent forms.
  2. Employees will be required to sign the chain of custody forms provided by the testing laboratory.
  3. Employees should disclose any medication, whether prescribed or over-the-counter, as well as any dietary intake that could alter a drug screen.
  4. The facility will use a laboratory for testing which meets the current scientific and technical guidelines for drug testing programs.
  5. A second test will be used on any positive screen.
  6. All positive drug tests will be verified by a medical review officer. If it is determined that there is a legitimate medical explanation for the positive results, the medical review officer shall report the test results as negative.

Confidentiality — Testing and test results will be handled confidentially with disclosure of results provided only to those individuals with a need to know. Upon request, employees will be provided a copy of test results.

Prescription drugs — Employees and applicants who have been taking legally prescribed drugs or over-the-counter medications should disclose this use prior to testing. A confidential consent form requesting information concerning this drug usage will be provided each employee/applicant prior to testing.

III. Insurance Provisions.

Because anesthesia providers are at increased risk of becoming addicted, this department will strive to make available as part of its benefits package both healthcare and disability insurance policies which have provisions for chemical dependency and mental health treatment.

IV. Narcotic Accountability.

A written, consistent process of narcotic accountability will be followed by all members of the department.

The use of all scheduled drugs, and others deemed necessary by the department administrators, will be managed as follows:

  1. All scheduled drugs will be kept under double lock and signed for only by authorized individuals according to regulatory guidelines, i.e., the Drug Enforcement Agency (DEA).
  2. Narcotics will not be exchanged between department members, not even narcotics signed out for the same patient between primary and relieving anesthetists.
  3. All unused portions of drugs will be returned to a centralized, mail slot type of locked compartment that can only be opened by the narcotics control officer, or they may be returned to a staffed pharmacy. If there is no centralized area, all narcotic wastage will follow facility guidelines with documented double witness wastage.
  4. Assays on unused portions of narcotics, as well as audits of anesthesia and PACU records, will be conducted periodically and if suspicion warrants.

V. Quality Assurance.

Written periodic evaluations of department members and random audits of written records will be a part of the QA process. This information remain confidential and undiscoverable until such time that intervention or discipline may be required. This review shall include anesthesia records, PACU notes and narcotic inventory/usage.

  1. Unusual trends, violations or errors will be documented and investigated within the department.
  2. When sufficient evidence exists that inappropriate narcotic usage has occurred, a specific investigation will begin and a more in-depth review of specific records.

VI. Documentation.

Appropriate documentation will commence upon suspicion of misuse of departmental pharmaceuticals, or signs of drug/alcohol abuse. Upon suspicion of substance misuse, documentation shall be as follows:

  1. Note changes in behavior such as appearance, demeanor, attendance, and being in the department when off duty.
  2. Documentation will be kept by the department head or supervisor in non-discoverable files, but may be made a part of the employee’s record should disciplinary action be warranted.
  3. Documentation shall include names of those that can substantiate the observations, and should include specific dates and circumstances of all notations.

VII. Confrontation.

When there is sufficient documented evidence of employee impairment, or when evidence exists that the employee is diverting controlled substances from the department, a confrontation will be planned. Employees shall be offered the option to self-report to an impaired professionals program (if such a program or legislation exists within the state of practice). A meeting or intervention shall be planned to confront the employee with documented questionable behavior. The planning and conduct of this confrontation shall be as follows:

A. A confrontation will be planned that includes:

  1. Sufficient documented evidence.
  2. The presence of the principle observers of the questionable behavior.
  3. A trained individual capable of conducting an intervention.
  4. Recognition of the potential for immediate placement of the employee in a facility for assessment and possible treatment.

B. An extended leave of absence shall be granted to the employee for chemical dependency treatment that leaves intact all applicable insurance plans and benefits. The individual will be advised how payment will continue to be provided for such benefits.

C. If the employee refuses to comply with a request that they be evaluated for chemical dependency the information collected to date will be submitted to the appropriate regulatory agency for further investigation and probable discipline.

VIII. Re-entry.

Anesthesia providers with a prior history of chemical dependency may (re)enter the department if they can show sufficient evidence of successful completion of treatment and documentation of active recovery. Applicants or employees with a prior history of chemical dependency will:

  1. Provide evidence of successful completion of drug/alcohol rehabilitation and sustained active recovery/sobriety.
  2. Possess current licensure, or any required registration.
  3. Comply with the conditions for active recertification as a CRNA, as determined by the Council on Recertification.
  4. Have their history kept in confidence and their anonymity protected until such time that they choose to divulge their anonymity.
  5. Be treated with respect and afforded all opportunities granted to others with disabilities.
  6. Abide fully with all departmental policies, and shall comply with the conditions set forth in a rigid written reentry contract.

Source: Developed by the American Association of Nurse Anesthetists Peer Assistance Advisors, August 1997, Park Ridge, IL. Web: www.aana.com/peer/policy.asp.