NSG/426 Week 4: Reporting Duties and Workplace Conflicts, sample paper

When the Waste Does Not Add Up: A Unit Policy for Reporting Suspected Controlled Substance Diversion by a Colleague

[Student Name]

University of Phoenix

NSG/426: Integrity in Practice: Ethic and Legal Considerations

Week 4 Assignment

[Instructor Name]

[Date]

The hospital, unit and events are a composite written for a model paper. No real person is described.

A composite medical-surgical nurse reviewing the automated dispensing cabinet report for her unit noticed a pattern. One colleague, a respected nurse with fifteen years on the unit, documented wasting partial doses of hydromorphone far more often than anyone else, usually without a second nurse's witness signature entered until the end of the shift. Two of her patients had complained of unrelieved pain on nights when she had documented giving hydromorphone. The nurse's first thought was loyalty to a friend; her second was the patients who might be in pain because the medication meant for them was going somewhere else. This paper explains the duties involved and presents a unit policy for reporting suspected controlled substance diversion.

Why Diversion Is a Multiple-Victim Problem

Berge et al. (2012) described drug diversion within health care facilities as a multiple-victim crime. Patients are harmed when they are denied medication, receive substituted or diluted drugs or are cared for by an impaired clinician; the diverting clinician is harmed by the progression of a substance use disorder and its risks, including overdose; coworkers may face suspicion; and the institution faces legal, financial and reputational consequences. The authors noted that diversion is often detected through patterns in dispensing data, such as excessive waste, frequent overrides and discrepancies between documented administration and patients' reports of pain, which are the patterns this nurse noticed.

Legal and Ethical Duties

Ethically, patients come first, and the ANA Code of Ethics directs nurses to act when a colleague's practice, including impairment, places patients at risk, using appropriate channels and with concern for the colleague as well (American Nurses Association [ANA], 2015). Legally, several duties apply. The hospital, as a registrant with the Drug Enforcement Administration, must notify the agency of the theft or significant loss of any controlled substance upon discovery (Other Security Controls for Practitioners, 2024). Many state nurse practice acts require nurses or employers to report to the board of nursing when a nurse's practice is impaired or when misconduct such as diversion is suspected. Failing to report can itself be grounds for discipline in some states.

The conflict the nurse feels is real: reporting a colleague can feel like betrayal and can strain working relationships. A clear policy reduces the burden on individual nurses by defining the steps, protecting reporters and ensuring the colleague is treated fairly.

The Policy

Purpose. To protect patients from harm related to controlled substance diversion, to define the duty and procedure for reporting suspected diversion and to ensure fair treatment and support for any staff member involved.

Scope. All licensed and unlicensed staff on the unit who handle, witness or have access to controlled substances.

Definitions. Diversion means the transfer of a controlled substance from its lawful and intended use, including theft, substitution, tampering or use by the staff member. Impaired practice means practice affected by substance use or another condition that compromises safety.

Recognizing concerns. Staff should be alert to behavioral signs, such as frequent unexplained absences from the unit, and to documentation patterns, such as excessive waste, waste without timely witness, frequent cabinet overrides, patients reporting unrelieved pain despite documented doses and removal of medications for patients not assigned to the staff member.

Reporting procedure. A staff member who suspects diversion reports it promptly and privately to the nurse manager or, if the manager is unavailable or involved, to the nursing supervisor or pharmacy diversion specialist. The report should describe observed facts, not conclusions. Staff should not confront the colleague, conduct their own investigation or discuss the concern with coworkers.

Investigation. The manager, with pharmacy and human resources, reviews dispensing data and records. If diversion is suspected, the staff member is interviewed privately and may be asked to undergo testing according to hospital policy. The staff member is removed from patient care during the investigation if patient safety requires it.

Patient safety. The manager reviews the care of affected patients, informs their providers of any concern about missed or substituted medication and ensures appropriate follow-up.

External reporting. Pharmacy reports theft or significant loss as required by federal regulation, and the chief nursing officer reports to the board of nursing as required by state law.

Protection of reporters. Staff who report in good faith are protected from retaliation, and the reporter's identity is kept confidential to the extent the law allows.

Support for the colleague. A staff member suspected or found to have a substance use disorder is referred to the employee assistance program and informed about the board's alternative-to-discipline program if one exists.

What the Nurse Did

The nurse wrote down what she had seen: the dates of the unwitnessed waste entries from the cabinet report and the two patients' complaints of pain, without names in her notes and without guessing at explanations. She asked the nurse manager for a private meeting the next morning and handed over her notes. The manager thanked her, told her she had done what the policy required and asked her not to discuss it with anyone. Within two weeks, pharmacy's audit confirmed the pattern, the colleague was removed from patient care, the affected patients' providers were informed and the colleague entered treatment through the state's alternative program. The reporting nurse was not told the details, which was difficult, but she was told that her report had been handled and that the unit's patients were safe.

Why the Policy Includes Support

Substance use disorders are illnesses that affect nurses as they affect others, and access to opioids increases risk. Boards of nursing in many states offer alternative-to-discipline programs that combine treatment and monitoring with a path back to practice, reflecting evidence that nurses who complete such programs can return to safe practice. A policy that treats diversion only as a crime discourages reporting and pushes affected nurses away from help; one that combines patient protection with support makes it more likely that problems will be reported early.

Conclusion

The pattern in the dispensing report placed the nurse in a real workplace conflict between loyalty to a colleague and duty to patients. Evidence shows that diversion harms patients, the diverting clinician and the organization, and law and ethics require action. A clear unit policy defines what to recognize, whom to tell, how to investigate, how to protect patients and reporters and how to support the colleague. With it, the nurse could report what she saw as facts, through proper channels, without having to decide alone what those facts meant.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Publishing.

Berge, K. H., Dillon, K. R., Sikkink, K. M., Taylor, T. K., & Lanier, W. L. (2012). Diversion of drugs within health care facilities, a multiple-victim crime: Patterns of diversion, scope, consequences, detection, and prevention. Mayo Clinic Proceedings, 87(7), 674-682. https://doi.org/10.1016/j.mayocp.2012.03.013

Other Security Controls for Practitioners, 21 C.F.R. § 1301.76 (2024). https://www.ecfr.gov/current/title-21/section-1301.76