Many have hire, for-cause drug tests, but should you perform random testing?

Providers share approaches to stop diversion, theft

A surgical tech takes fentanyl from an anesthesia tray and substitutes it with a normal saline solution (NSS). He is caught when someone sees him taking the drug from the unattended anesthesia tray.

An anesthesia resident diverts from the fentanyl waste and gives the pharmacist NSS in the syringes. The pharmacist identifies the solution isn't fentanyl after performing a light refraction on each dose.

These actual situations from one outpatient surgery program demonstrate the importance of monitoring staff and physicians for drug use. But should you go as far as to perform random testing?

That's a question that continues to spark controversy. While pre-placement and for-cause drug testing are commonplace in health care facilities, managers have widely different views on random drug testing. A 2006 survey by the Society for Human Resource Management found that only 39% of employers randomly tested employees after they were hired. In comparison, 84% of employers required new hires to pass drug screenings, and 73% tested workers when drug use was suspected.

One study that targeted physicians suggested that health care facilities perform random drug testing, as well as pre-employment and for cause testing, on doctors.1 "Testing complements prevention, education, early intervention and treatment initiatives," the researchers said. "However, while being a physician is a risk group, we strongly recommend that specialties with greatest access and at greatest risk of occupational exposure (anesthesiology, surgery, emergency medicine), are the first priority for monitoring."

Marshfield (WI) Clinic does perform random drug testing in departments deemed to be higher risk because they store narcotics, including ambulatory surgery and gastrointestinal surgery. The testing panels typically include about 10-12 drugs. They vary according to what drugs are used in the unit, but they often include fentanyl, midazolam, cocaine, amphetamines, and barbiturates. "It's not truly a program meant to detect drug use in our employees as much as it is to prevent, or assist in preventing, theft and diversion of drugs," says Bruce Cunha, manager of employee health and safety, and infection prevention and control.

The managers determine which employees in their areas should be tested based on who has direct access. Those tested may include anesthesiologists, physicians, nurses, and technicians. About 10% of the employees are included on the list for potential random drug testing, and about 10% of that group are tested over the course of a year, which equals about 70 employees, he says.

The random testing is conducted quarterly. An outside medical review officer (MRO) sends the clinic a random list of employees to be tested. The clinic pays $40 for this service. Any positive tests are confirmed by the MRO at a cost of $60 each. The MRO seeks verification that the employee has a valid prescription. "If there is the potential that they were diverting or that there was theft, our employees have the ability to get into treatment," Cunha says. Employees caught stealing drugs, especially in situations that may have jeopardized patient safety, may be terminated, he adds.

Marshfield also performs drug testing at hire and tests for cause when there is a reasonable suspicion of drug use.

"With new hires, we always get a few," Cunha says.

All managers have been trained on what to look for as part of the for-cause testing. They have a form they use to document why they have reasonable suspicion. Once the form is completed, the employee is tested for all street drugs and alcohol. "If the person comes back positive, they are allowed to go to a treatment program, depending on circumstances, but mostly we do," Cunha says. "We want them to come back as good employees."

Consider drug testing when there has been an adverse event, he says. "I do believe that any incident or accident where there is a potential that the error was the result of a bad decision on the part of an employee should be evaluated for the potential that a substance was part of the reason for the error," Cunha says.

Others don't believe drug testing is appropriate after a sentinel event in most cases. "If we had 'reasonable suspicion' or 'probable cause' that the health care workers involved were impaired or under the influence of an illegal/controlled substance or alcohol, we would conduct substance abuse screening," says JoAnn Shea, CHON-S, MS, ARNP, director of employee health services at Tampa (FL) General Hospital. If not, requiring a urine drug screen could be considered as a search and seizure without any regulatory requirements to back this action up, Shea says. "If you could absolutely identify one individual [as causing an adverse event], then yes, maybe it would be appropriate, but only if there were state regulatory requirements to do this," she says.

The Accreditation Association for Ambulatory Health Care (AAAHC) doesn't require drug testing after an adverse incident/sentinel event, according to Michon Villanueva, assistant director of accreditation services. If an organization chooses to require drug testing, AAAHC generally would require that the organization adopt this as part of a policy and have it approved by the organization's governing body, she says. The Joint Commission requires that all organizations experiencing a sentinel event conduct a thorough and credible root-cause analysis. A spokesperson for The Joint Commission says the organization doesn't say a facility must drug test unless required by the organization's policy and/or law and regulation. The organization is advised to include the risk manager and human resource leader in any discussions about drug tests.

In terms of drug use, facilities that aren't looking at theft and diversion really need to be, Cunha says. "If you have multiple people accessing narcotics, like in an ASC with anesthesia, control of that becomes a real problem," he says. For example, are the medications being measured exactly and wasted correctly? "[Drug testing] adds another layer," he says. "It shows you're serious about controlling those substances."

Tampa General doesn't perform random testing, but does test for reasonable suspicion, pre-employment, and follow-up for recovery, Shea says.

The hospital doesn't randomly drug test because the facility is so large that such a program would be difficult to manage, she says. Also, she estimates that it would cost $20,000 to $30,000 a year to conduct random testing. "Is it really worth it? I'd rather spend that money on promoting health for employees and spending time identifying the diverters," Shea says.

However, if you're a small ambulatory surgery center, at least have a method to monitor what drugs are being diverted, she advises. "Make sure the waste is really wasted," Shea says.

At Tampa General, the pre-employment drug test is conducted on all employees, travelers, and contract workers, she says. Additionally, "the OR pharmacist monitors all anesthesiology waste as well as the surgeons'," Shea says. "They require all waste to be returned to them, and they compare the wastage with the actual OR narcotic usage."

The hospital's "reasonable suspicion" tested is boosted by use of the AccuDose-Rx system (McKesson, Cranberry, PA; to monitor narcotic use. The best way to review drug utilization is by frequency and by department, Shea says. Her hospital's pharmacy staff set up the tracking database to produce monthly reports indicating how many doses of an injection are given by each nurse compared to other nurses on their unit or in the entire hospital, and it can track the dosage by the date and time it was removed, Shea says.

Shea and the pharmacy nurse liaison review the spreadsheets monthly and identify and investigate discrepancies. "We notice trends," she says. "Most of our diversions are identified that way." In the past five years, about three outpatient surgery employees who were diverting have been identified through this system, she says. "We're on top of it," she says. "Employees know that."

Diprivan and fentanyl are becoming drugs of choice in health care because they're being used for conscious sedation outside of the OR — in step-down units, for example, Shea warns.

When there is a reasonable suspicion that an ambulatory surgery employee is using or diverting drugs, keep in mind that employees are protected by the Fourth Amendment, and urine specimen is considered a "search and seizure," she points out. "If you request one, make sure you have objective information and documentation that it's necessary," Shea emphasizes. (See form used at Tampa General.) If employees refuse, they are immediately terminated, she says. "We're not going to [request] that unless we're sure we have enough information to require it," Shea says.

When employees do take the test, it costs the facility $90 per person, which includes MRO fees. The MRO examines the lab test and the results. Employees who are caught diverting are sent into treatment, she says. When employee finish treatment, the ones who return to the hospital are enrolled in an Employee Recovery Program and must sign a return-to-work Agreement that includes monitoring of their recovery program and random drug testing for up to five years. At least once a month, those employees are tested.

"We have a recovery rate of 80% when employees come back to work," Shea says, which she attributes partially to an excellent state program that monitors licensed professionals. "We're a big supporter of that," she says. "We've seen success."


  1. Gold MS, Frost-Pineda K. Random mandatory drug testing: A potential system-level solution? Rapid Response. Ann Intern Med 2006. Accessed at


Online resources are available from the Society for Human Resource Management, including: