A registered nurse (RN), 32, was sentenced to 54 months in prison and three years of supervised release for tampering with vials of injectable Hydromorphone. She was also ordered to pay a $3,000 fine.
According to court documents, from July to November 2020, the RN was employed as a contract nurse in the Clinical Pre/Post Procedure Unit (CPPU) at a medical center in Winston-Salem, North Carolina. In that capacity she was authorized to access the Pyxes machine located in the CPPU for the purpose of dispensing controlled substances, including injectable Hydromorphone, to patients at the direction of prescribing doctors.
Vials of drugs stored in the Pyxes machine at the medical center were held in container packages with each individual vial sealed with tamper evident seals and caps. From July 2020 through November 2020, the RN opened container packages containing vials of injectable Hydromorphone that were stored in the Pyxes machine. She then removed the vials from those container packages and opened the vials for the purpose of converting and consuming the Hydromorphone by injecting the drug into herself.
After removing and converting injectable Hydromorphone, the RN injected saline solution into the vials to conceal her conversion of the drugs and replaced the lids of the vials with glue. She then placed the tampered-with vials into the opened container packages, closed and resealed the container packages, and then left those container packages in the locked and secured Pyxes machine. This was done with the knowledge that CPPU nurses would then unknowingly administer the compromised vials to patients.
Issue:
Experts estimate that 10–15 percent of our nation’s population struggles with impairment from alcohol or drug dependency. Nurses, as part of this statistic, are distinct due to their ability to access drugs in the workplace. Because as many as one in ten nurses could be affected by a substance use disorder, it is critical that each facility implements a proactive diversion-prevention program. The consequences of failure to do this include a negative impact on residents’ quality of care, legal and ethical concerns, and potential for high scope and severity citations once a diversion problem is uncovered. Nurses who divert medications have developed a number of ways to conceal diversion. Efforts must identify the types of medications most likely to be taken, signs that diversion has taken place, and signs of impairment.
Discussion Points:
- Review your policies and procedures on preventing, identifying, and responding to drug diversion. Update as needed.
- Train appropriate staff on actions that can be taken to prevent, identify, and respond to any suspicion of drug diversion. Provide education on the impact of drug diversion on residents as a form of abuse and neglect, staff responsibility to report concerns immediately, and the consequences of theft of controlled substances. Document that the trainings occurred, and place the signed document in each employee’s education file.
- Periodically audit to ensure that all controlled substances are accounted for each shift, and that proper documentation of controlled substances has occurred. Your consultant pharmacist can be included in this effort.
