It started with a few sips of Demerol left over in ampules after a case. When she got away with recording the leftovers she drank as "waste," recovery room nurse Drea Lynn Gibson, RN, started stealing whole ampules of Demerol for her use from the Plastic Surgery Center in Bellevue, Wash., documenting the medication as being administered to patients. As her addiction worsened and she ramped up her intake to 2 to 3 ampules a day, Ms. Gibson got careless — and then she got caught. She broke open the ampules, consumed their contents and super-glued them back together, replacing the painkiller with saline solution to cover her tracks.

Her secret was revealed when a patient complained that she was still in pain after receiving the tampered Demerol and when the evidence of Ms. Gibson's drug diversion — bottles of Super Glue and broken ampules — was found in the recovery room. Last month, the U.S. District Court in Seattle sentenced the 43-year-old nurse to a year and a day in prison and 3 years of supervised release for product tampering in violation of federal law. "Replacing the Demerol with epinephrine shows she was willing to put other people in pain and even at risk of death to treat her own pain," said U.S. District Judge Ricardo Martinez.

Think it couldn't happen in your facility? Think again. A surgical administrator recalls the time a nurse anesthetist was caught stealing liquid cocaine from her hospital's controlled substances storage by sticking a small-gauge needle through the dot in the "i" in cocaine printed on the drug's peel-top container. That nurse also replaced the stolen narcotic with saline solution. Another administrator says she never suspected one of her facility's best OR nurses of diverting and abusing propofol — until someone at a neighboring store spotted the RN with a needle sticking out from under her sleeve and reported it to the ASC. The warning signs were there, say that nurse's former supervisors, but they were easy to overlook because she'd been such a great employee.

Addiction specialists, recovering addicts and administrators who've had drugs diverted from underneath their noses will all tell you the same thing: Someone in the throes of addiction will do whatever it takes to get her hands on the next fix. To safeguard your staff and patients, you've got to stay one step ahead by enforcing tight inventory controls and looking out for the warning signs of drug diversion.

Close watch on narcotics
Your surgical facility is a virtual goldmine to the drug addict. "We in anesthesia have remarkable access to these drugs," says Jay Horowitz, CRNA, president of Quality Anesthesia Care Corp. in Sarasota, Fla. "There are a million ways to divert them for personal use." The first step you can take to prevent that diversion is to implement very strict inventory control of your drug supplies.

For opioids and other controlled substances, you're already bound by law to have certain measures in place, such as locked storage with limited access and precise counts and documentation when drugs are pulled and wasted. Diligent surveillance of drug orders, access and wastage can help you detect patterns that could signal diversion, such as a sudden spike in the amount of narcotics being signed out by a particular practitioner, says Art Zwerling, CRNA, DNP, DAAPM, senior advisor for the American Association of Nurse Anesthetists' Peer Assistance program. He recommends automatic drug dispensing systems that track individual providers' usage and keep detailed, electronic records you can review at any time.

Implement a system of checks and balances to monitor both the administration and the wasting of anesthesia drugs, says Leroy Kromis, PharmD, medication safety officer for the Lehigh Valley (Pa.) Health Network. "Anything charted as being administered on patients should be reconciled by a second individual." For example, if Anesthesiologist X says that he's given a fentanyl infusion, a second person should be there, making sure that he's properly charting and documenting the drug's usage. At least 2 professionals should witness narcotic waste, says Dr. Kromis. That doesn't mean a second individual just signs off on the waste; that person must physically witness the process. You may also consider randomly testing waste to make sure that what's being submitted is the actual drug, since a common method of drug diversion is to draw up a syringe of medication and refill the vial with saline solution. Finally, encourage staff to adhere to basic safe medication practices; for example, draw up syringes immediately before using them, and don't leave narcotics out in the open, unattended.

Problem with propofol
Because they aren't regulated as strictly as narcotics, non-controlled substances may pose the biggest risk of diversion at your facility. Propofol is a particular concern, as research has shown abuse of the drug to be rising among anesthesia providers. "Very few facilities count it or pay much attention to it at all," says Mr. Zwerling. "It's easily diverted without detection, and it's becoming a real problem." In a new position statement released this year, the AANA called on facilities to put propofol under lock and key and supported the Drug Enforcement Agency's decision to consider giving it controlled status. The American Society of Anesthesi-ologists went a step further, recommending that the DEA label propofol a controlled substance in the hopes that the "tighter control and monitoring that accompany scheduling of the drug" would "reduce the potential for abuse."

Until the DEA takes that step, you should come up with a plan for securing propofol. Some facilities have already begun locking up propofol and subjecting it to the same counts, documentation and surveillance as controlled substances. Others have chosen to store it in locked cabinets and limit access, but forgo the extra paperwork involved in counting usage and waste. Pharmacy consultant Sheldon Sones, RPh, FASCP, recommends you keep propofol in a locked drawer or cabinet separate from controlled substances so you're not increasing traffic to narcotics.

The role of drug screening
Research has shown the military's policy of random employee drug testing has been effective in reducing the incidence of drug abuse among military personnel. Mr. Zwerling believes the same strategy can help reduce the rate of abuse among anesthesia providers. "I really think that every anesthesia provider should be subject to random urine drug screening," he says. "If you think you have to come in and give a urine sample, it makes you think twice about what you're going to do."

You can use drug screening both as a preventive measure to deter drug diversion and as a tool for confirming suspicions raised about a staff member. Develop a written policy that explains exactly how the drug screening will work in practice: the consent forms employees will be required to sign, how specimens will be handled and tested, how positive results will be addressed and so on. The AANA's Peer Assistance Advisors Group has a model random drug screening policy available at www.aana.com that can serve as a good framework, but should be adapted to meet your facility's needs. Your drug screening policy should also conform to the guidelines set forth by the Substance Abuse and Mental Health Services Administration (www.samhsa.gov).

The cost of a urinary drug test depends on the lab you use and the number of substances you test for. Mr. Zwerling estimates that screening tests cost between $69 and $148, and confirmatory tests range from $92 to $165, but that "testing for fentanyl, fentanyl analogues and propofol can add significantly to these costs."

Confronting the abuser
You and your surgical team have an ethical obligation to recognize and respond to personnel who may be impaired by substance abuse, as it can have a direct adverse effect on patient safety. Sheila Mitchell, RN, BSN, MS, CNOR, perioperative nursing specialist for AORN's Center for Nursing Practice, recommends that you incorporate lessons on how to recognize an impaired colleague and go over your facility's policy for handling suspected drug abuse and diversion during staff training. (See "Signs and Behaviors of Impaired Colleagues.") In crafting your policy, make sure that it fosters a "culture of safety" in which staff "would not feel threatened if they report situations that can result in adverse consequences for patients," says Ms. Mitchell.

Before you confront an employee suspected of abusing drugs, make sure you've documented all the abnormal behaviors and when you observed them. "If it really appears that it's a chemical dependency issue, your facility needs to be prepared to do an intervention," says Mr. Zwerling. Have written policies and procedures in place that spell out exactly how such an intervention will take place. For example, according to the AANA's Model Policy for Chemical Dependency, confrontation with an employee suspected of abusing drugs should include:

1. sufficient documented evidence;
2. the presence of the principal observers of the questionable behavior;
3. a trained individual capable of conducting an intervention; and
4. a recognition of the potential for immediate placement of the employee in a facility for assessment and possible treatment.

Contact your state's AANA peer assistance advisor, chemical dependency program, board of nursing or medical board (depending on whether it's a nurse or physician) for advice on how to proceed with an intervention and treatment for employees struggling with addiction. You can search the AANA's Peer Assistance Resource Directory at webapps.aana.com/Peer/directory.asp for contacts specific to your state, or call the organization's national Peer Assistance Hotline at (800) 654-5167.

While it's essential to remove drug abusers from clinical practice as soon as possible, Mr. Zwerling says the goal is to get the addict into treatment so she can heal and eventually re-enter the workplace. Depending on the circumstances, a nurse or physician may be able to return to her previous position at your facility while being monitored by the state licensing board, or she may have to be redirected to a different career path without access to drugs.

Confronting a colleague or employee you suspect may be abusing drugs is a difficult and delicate task — but it's one that ultimately may save lives. "The last thing we want to do is bury any more anesthesia providers," says Mr. Zwerling.