Our Guest: Maggie Ortiz, RN, MSN CEO Advocates for Nurses
Ever feel like nursing school didn’t prepare you for the real world? From medication diversion risks to navigating legal issues, there’s a lot healthcare professionals may learn after navigating legal challenges. Join us as Maggie, founder of Advocates for Nurses, tackles some “hot topics” with myself, a pharmacist and diversion specialist! Get expert insights, practical tips, and a unique perspective on how to build a thriving and safe nursing career. Tune in for real talk, relatable advice, and answers to the questions that may be keeping nurses up at night.
Transcript:
Terri
Welcome back, listeners. Today’s podcast is with Maggie Ortiz. Maggie is a nurse and the CEO for advocates for nurses. Welcome, Maggie. It’s good to have you.
Maggie
Thank you for having me. Thank you. Thank you. Thank you.
Terri
So let’s start by you telling us about advocate for nurses. I can kind of guess sort of what you do in general, but tell us about what you do, how the idea for the company came about.
Maggie
Sure. So then that will probably just lead me, and I got to talk a little bit about just some of my history as being a nurse. So I’ve been a nurse for 23 years. I started with an associate’s degree, and in my nurse, people know that it’s hard for us to move around with an associate’s degree because they do put restrictions on where it is we can go as far as, like, leadership. So at 15 years, I decided to get my bachelor’s 15 years into practicing. But then I was like, no, no. If I’m going to get my bachelor’s, I’m just going to get my master’s. So I got my master’s in leadership. During that period, I did spend some time at a board of nursing.
Maggie
I was formally trained as an investigator and spend a short period of time there where I saw some things I thought were a little concerning, most specifically, just some lack of due process, that nurses were not being extended what I now know to be, like, mitigating circumstances. And I left that entity, went back to the hospital where I was comfortable, and then started doing some of my own research. So this is roughly about a decade ago, and then I’m studying up some administrative law. People are reaching out to me. I become a civil expert, and then I cross over and become an administrative expert, creating advocates for nurses, because nurses were reaching out to me because they didn’t understand the investigative process.
Maggie
They didn’t understand that they got allegations in the mail, and they have 30 days to respond, and they don’t even know what these words are. And, oh, by the way, this was a year ago, and they’ve taken care of thousands of people, as you know, as a pharmacist. Sure, we go to formal training, but while we’re drowning in educational material for us, as the RN and I can’t speak for other disciplines, we don’t dwell a long time on legal. The administrative process, the process of holding a professional license and what that means. And I don’t mean malpractice. I mean holding a professional license. That entity giving you that privilege, whether it’s a board, whether it’s the, you know, HHS, whether it’s under the governor, what that means. We don’t understand the intersection of our license and that entity.
Maggie
We don’t realize that entity is there for the public and not for our protection. So we are drowning in medical terminology, and we learn basic stuff about administrative law. Texas is the only state that does require any provider would be yourself as well, to take jurisprudence. It is the intersection, basically, of your license and the law. It’s a six hour course, and then every third cycle you have to take the three ece. But we’re the only state, and that’s a brief overview. And I know that answer got really long, but the lack of education about the holding a professional license is so profound amongst every discipline I have found. So for nurses, I am their gift to them. I provide education. I do what I can to help nurses understand that process and pray that they never stand there.
Terri
Okay, so another business that has come out of your experiences and discovering where there are kind of holes in the system, and people start asking you questions and you’re like, well, we could turn this into an entire business. And I think, you know, I will comment that I think all of us in the professions don’t think we need to know all that. Right? Everything. I’m going to do my job. I’m going to do it well, and everything’s going to be fine. But sometimes it’s not fine. I know that the board of Pharmacy in California requires law ces. There’s 1 hour of law, 1 hour ethics for every pharmacist every other year when they renew their license. But it’s a little bit, and it’s often repetitive.
Terri
You know, every two years, you’re kind of hearing the same thing, but it’s certainly not as much as the 6 hours, which, again, is just an overview. So, yeah, it is important to, we have to be prepared even though we think it’ll never happen. What kinds of things? You’re there for advice, obviously, if they call you. But do you, does the organization offer anything proactive to nurses to train them?
Maggie
So, first and foremost, I’m glad you said I offer advice. I’m not a lawyer and I never give legal advice. So I always like to say that as well. I’m an advocate. Does the organization know? They don’t? More often than not now I have seen travel agencies offer some education and. You mean like education once you’re under investigation or some basic education? I guess I should clarify that question.
Terri
Yeah, basic information in order. I mean if you’ve discovered this gap and they’re coming to you for advice at certain points along their career, is there any preemptive type of overview that you give them or try to stay out of trouble? Yeah, sure.
Maggie
For sure. For sure. So that’s kind of like my foundation now because yes, I can help you and your legal team when you’re under investigation. I can write up your rebuttal. I can, you know, be your expert. But how do we get you not to stand there? So that’s a great question. So I teach charting to protect your livelihood is actually the course that I teach because you and I both know when we’re called or we’re asked to look at something, what are we looking at? The medical record. And it’s what you did or did not document. And so if it’s not there, then again it was a year ago. Is this significant to you enough that you remember this? You don’t? So I teach that and then I have a handout that’s now on my website. It’s like $5.
Maggie
It’s about the investigative process with some hyperlinks. It’s one to twelve. What is a complaint? Who can make a complaint? What’s an allegation? What’s an informal conference? Because some of that is the education that we’re missing. So I just dumbed that down as well. And then any nurse can come to me, I put my phone number out there, I put my email out there because I don’t want a nurse ever to struggle alone. Unfortunately the incidence of suicide amongst nurses is very high. It’s equivalent to, if you look at the research that of like war veterans post COVID and now at slap down that they got a complaint from the board of nursing, right. That they carry shame. No, they don’t want to tell anyone. So you know, I will speak to any nurse. I’ll get you some guidance. What do you need?
Maggie
How can I help you? You know, with if they don’t have, even if they don’t have a lawyer, right. I’ll get you some educational information. I’m not giving you legal advice, just giving you some guidance.
Terri
Right? Yeah. And when you do get a complaint, I imagine it’s at least at the beginning, it’s kind of hard to think rationally, too, because you just start to go into this, like, oh, my gosh, oh, my gosh, oh, my gosh. And sometimes we don’t know what we don’t know. So then we kind of step into something that we shouldn’t have done, that wasn’t the direction we should have gone.
Maggie
And then you start talking to the board of nursing and. Or this entity, you start saying things again that maybe you shouldn’t be saying, or you don’t know what the record says, and then you just start talking and, you know, I was the investigator and I was supposed to unbiasedly just be writing down everything you said. Now, in a civil criminal, what would they be telling you? Why would you know, plead the fans, please, whatever the word is. You know, I mean, I haven’t been read my Miranda rights. Do you know, do you have your full, complete file? That’s some of the language that I teach nurses or any professional. Why are you talking to anyone if you don’t know what the full, complete file is? Because that’s not fair. Do you even know what happened? You’re speaking out of turn.
Maggie
And could harm you. It’s not that I don’t want you to comply with the board of nursing. You should. But part of your due process rights is to know. You may not know who the complainant is, and it’s specific to your state. Texas will never allow you to know who filed that complaint. Other states will print to you exact words who sign that right to you.
Terri
So every state is different.
Maggie
Every board is different. So when a nurse reaches out to me, you know, because I’m trained to do that kind of stuff, I go to your board of nursing. There’s three sections I’m going to look at. I’m going to use the display matrix. I’m going to look at some different things and. Or the specific violations and the allegations that they are alleging. So that’s going to drive part of my research to help you find out what exactly is happening here.
Terri
Okay. All right. And you had said, you know, a year from now, if they’re coming back to you and it’s. You’re not going to remember that. And I do. Years and years. Early in my career, somebody once told me, I don’t even remember who it was. If something weird happens on your shift. Just make a note to yourself so that you remember what it was or there were some unusual circumstances. And so I did. I had my little notebook that occasionally I would throw something in there about, you know, even told the physician this was not appropriate or, you know, what have you. And if it was something I decided I had to just go ahead and let through because I didn’t think it was quite appropriate, but it wasn’t the hill to die on.
Terri
I did have a few of those, and I remember one in particular like, oh, my gosh, this is going to be the time that I refuse to fill. In the end, we worked it out, but that was probably about an hour and a half of really, you’re going to kill them. And it was a neonate, so it was very clear that the dose was way wrong.
Maggie
I just want to pause there for just a minute because I know, you know, because people do take those notes and I get asked about this as well. Can I make a note? You can, but you would never include, like, you wouldn’t take a sticker from, you know, the patient chart. You see that in, you know, maybe like an ER setting where we still do print out some stuff, right? You would never take that sticker. You would make a note to yourself with no hipaa information. So that, again, that you would remember that you wouldn’t take anything from the facility. You wouldn’t take a flow sheet. You wouldn’t remove anything from the organization because, again, that can be used against you. And I have seen that used against nurses. They said, let me, again, they were under arrest. Let me see my notes. Well, what were you using?
Maggie
Oh, the flow sheet. And then, you know, what the board added on, or, and then human resources, because they were already retaliating against that nurse. They’re on the phone, they’re talking. She’s like, I don’t remember this, but let me get my notes. Oh, really? What notes were you referencing? Oh, I took some flow sheets and then you. They added on that complete. That was reason. Now then to send her to the board of nursing. Everything else was, you know, questionable. Just going to fire you. But now I have grounds to actually report you to the board of nursing. And they did.
Terri
Good point. So, yeah, what date, location. Can you include initials, the patient. So you know who you’re talking about? Like, if it comes up. Yes, but yeah, just your description of what occurred. Nothing. Because if you’re writing it down, it.
Maggie
Was probably significant enough for you to remember it and not only that, if you’re taking that step, then I would also highly suggest that you also maybe reach out to your leadership and just something unbiased, something that doesn’t look inflammatory, something that’s just. This happened. Encrypted. Everyone has the ability to encrypt. You just google the video. It’s on your email. You have to go to, like, three tabs over, make sure you’re sending anything about anything encrypted. I don’t care if I’m still just using a patient initials. I don’t care. That’s just my, you know, we learn about this, it can be used against you, and they just drop something. And this happened with this physician. We did get it resolved. But I just want you know, to know about this in something that is just, again, another reminder.
Maggie
Because if you made a note to yourself in a notebook, you know what I mean?
Terri
You say, yeah, that’s true. FYI, to your management.
Maggie
And that can be found, I promise you, if, you know, and I would write a note to myself, sent an email to Bob. So I know as well, in that little note, that I also sent something digital.
Terri
Yeah, no, good points. Yeah, very good points. All right. And you had said, you know, if it’s not documented, it didn’t happen. And I think that just that alone can get people in trouble. And I know from a diversion investigation perspective, right, you’ve got out the chart, you’re doing an investigation, something looks a little funny, and then it’s like, come on. There’s, you know, there’s no pain assessments, there’s no pre and there’s no post. I know you’re busy, but now I don’t have anything to compare this to. And then.
Maggie
Nurses, nurses, please pause there. Please pause there, ma’am, please. To my nurse, people. So did you hear what she just said? She is a pharmacist who’s trying to help you. And so she just said she went to the medical record and there was no pain assessment. And then you deviated from the mar, which said if the pain was eight to ten, that you were supposed to give an iv intervention that got sent on her purview because you gave Vicodin. And you know what? She doesn’t even know if the patient’s pain was managed because you know what you didn’t do? Write a note.
Terri
Yeah, very true. Very true. Or I’ve seen in charts where they’ve got a non controlled ibuprofen for, say, moderate pain, and then they have an opioid for severe pain, and the nurse gives both. And the patient had both pain scores, you know, a moderate and a severe at the same time. And both meds were given. It’s like, well, okay, you know, but that’s not according to the orders. So did you keep one for yourself, or did you really give them both because, you know, it works better together or, you know.
Maggie
Correct. And so just repeat that again. So could you give an iv intervention? So patient has ten out of ten pain. Can I give an iv intervention and a po intervention?
Terri
Honestly, it depends on the order.
Maggie
Please walk me through that. And I agree. Cause if I looked at the order and even that, if I know that my patients in horrible pain, you know, what’s gonna get them out of pain right now is the iv intervention, which is gonna have a much shorter half life than the po intervention that I’m going to give them. So hopefully, I’m going to give them the iv, and then when the po. Gets on board. But then I have to just, like you said, look at the order, and if it is appropriate for the patient to have both, that I’m clarifying that not only with the order, I can call the doctor, I can call you. I love to call the pharmacist. Hey, what do you think about this? You know, this is my pain, my patients having this much pain.
Maggie
This is what the order says. What’s a reasonable, you know, thing to do? And then, no disrespect, but I’m writing down your name, because I am. You’re part of my team, and I am trying to figure this out with you. And so why? My responsibility is to document my communication with another healthcare provider. So I love this. I think that this needs to be talked about more, so please expand on that.
Terri
Yeah, yeah, no, it’s. And I think, you know, sometimes when doing audits and when looking at it, you can kind of see what the nurse was trying to do, but unfortunately, it was out of their scope to make those decisions, and so they weren’t supposed to do that. And some of the recommendations that I have to the managers of the area, and you see this a lot actually, in a pacu, because there’s all kinds of things going on, is you need to take this back to whoever it is that looks at your order sets, because your order sets do not allow your nurses to do what their clinical experience has shown them works for the patients.
Terri
And then what makes it worse is if ten nurses, nine, follow the order sets, or at least it appears that they’re following the order sets the way they’re charting and one doesn’t. So that one that says, well, clinically, this is what the patient needed. It’s like, but you’re an outlier. So you’re an outlier. Is it because you’re trying to manage your patients more effectively or is it because you are diverting or. But the bottom line is you’re not following those orders. Your charting does not indicate that you’re following those orders. So sometimes it’s a matter of going back to the order sets and really thinking through. And you know what’s bad is physicians don’t want to be bothered. You know that as a nurse.
Terri
So these order sets are written in a way that you don’t have to bother them, but that doesn’t work for every patient and every condition. There are exceptions. And so when a nurse tries to. Well, when a nurse ignores the order set in order not to bother the physician but steps outside that order set, they are now outside of their scope, and that doesn’t look well, especially if they’re doing it routinely.
Maggie
And I think that you taught, you highlight some good points. So clinical judgment, aka what a nurse would consider nursing judgment. And just like you said, that does go outside of your scope. And, you know, another good point that you do highlight and I want to talk about is the setting that you referenced is Pacu, right, where you have the anesthesia order sets. And so you’re giving just over those nurses who don’t know the phase one is different than phase two. Phase one is right out of the operating room where your patient could be having a lot of pain. You may be giving them fentanyl every three minutes. And that’s what your order set says based on, obviously your vital signs. And then when you move to phase two.
Maggie
So then some nurses don’t realize that those orders do not apply to you any longer because now you’re in a phase two setting, you know what I mean? And some of that overlap and understanding your department and where you’re at. And then if you need clarification and or, you know, the patient, that outlier, the patient had hernia repair, you know, something that’s, or their block didn’t work. And it is appropriate for now you to give them some other interventions. But you did leave that your area, your scope, or you deviated from what the order said. So you do have to go to the doctor and get another order. And communication is a huge problem between nurses and physicians. And yes, they scream at us.
Terri
They yell at us.
Maggie
Don’t be bothered. They have order sets. I mean, some of the doctors I’ve even respect, I respect, and that’s very few, unfortunately, because of the way that they do, can treat nurses. You know, I’ve seen them as well, the little, you know, like there’s an order. Like if I’m coming to you, it’s because it fell outside of that order and I need some guidance. So, you know, I think that’s really important for nurses to understand. When the chart is looked at. And like you said, audited, the first few things that are going to be looked at are the pain assessment, the order, the policy, and then what are the standards of care? And those are things like, you’re the expert pharmacist and I will be the expert nurse. These are things. And again, if you deviate from that, then I can’t help you.
Maggie
There really is nothing that can be done now. You’re right. No, you did talk to the anesthesiologist and I can see in a note that you did. Okay, okay. You can walk me through it, then I can maybe help you with some mitigating circumstances. But you still deviated from that and it still does appear that you, as the RN, and we’re talking about the RN, we’re not talking about the MP. We’re talking about the RN deviating from what their scope is. You’re not a prescriber, you’re not an order. You do have a scope of practice and we respect and you know what we do, but you gotta follow what the order states.
Terri
Yeah. And it’s kind of a, it’s a little bit, I don’t know, I wanna, I don’t wanna say fine line because I don’t know how fine it is, but you have to protect yourself. But learn how to do that without driving your physician crazy. And so if the orders are use fentanyl first up to 200 mics, and then switch to hydromorphone, you use fentanyl a couple of times, it’s not working like you would expect, and you want to switch to the hydromorphone to see if that has a better effect. You’re falling outside the order. So you’re doing what you think is best for the patient, but you’re falling outside the orders. And now you’re opening yourself up to a problem. And again, that’s where I say sometimes it’s the order sets that need to be reviewed and looked at.
Terri
Because if the whole department is finding that hydromorphone is the better route to go most of the time. Then why do the order sets, say, start with fentanyl? Right. So then that’s kind of a collaborative thing. But then again then you may have a patient that, you know, it’s going to be the other way around. So now you got an order set that says the other thing. So order sets have their place, but they can also be part of the problem, especially in a setting like that.
Maggie
Yeah, I’ve seen recently there’s, I think three, four, I think upwards of six people that I, nurses I worked within the last year that for whatever reason, I don’t know if it was an audit, I don’t know what alerted, but then their chart got alerted and so they went and looked at them. Even one nurse, she’s been a nurse for 30 years and she was doing on like a step down unit. Med surg unit. No, because I believe it’s med surg because she had like eight patients. So, you know, she went in, Bob said his pain was nine. He didn’t like the morphine, didn’t like the way it made him feel. Okay. Okay. Okay. I want the viking. Absolutely. Do you think she cares? No, but you already said that she deviated from the policy. What does the policy say?
Maggie
You said the pain was nine. The order says that the pain is nine. It’s an iv intervention. So then it’s okay that you deviate, but you gotta, hey, doctor Smith, you know what? He’s saying no to this. So then that standing order that order said has to be changed and then she did it six times. And what did you just talk about that trend?
Terri
Yeah.
Maggie
So how could she defend that in front of the board of nursing? No patient complaints. Was there any drug missing? There was no drug missing at all. There was no, it was. They, it was basically violations. They didn’t offer her diversion because there was no wasting problems. It was a, it was documentation, errors. It was fraudulent document. It was.
Terri
Yeah, yes. Yeah. And it’s, you know what I typically tell nurses is that you’re probably okay with a one time deviation. If you put a note, you know, patient prefers, go ahead, put that in the note. Step outside of the orders. If it’s something, they’re in pain, you can’t reach the physician. It just doesn’t make sense at this point to get that order. But that’s it.
Maggie
One time.
Terri
Now you’ve got 4 hours, 6 hours, whatever it is to. And this is, of course, if this is what the patient wants all the time. Because sometimes I’ll see that it’s like they don’t ever want, they only want this, then change the orders. But to see it repeatedly stepping outside, it’s like, okay, you knew that, you put the note in there. Why are you leaving it for the next shift to deal with all over again? Or why did you not do it and get it taken care of? So now you got time. Now you need to put in the call to the physician and get the order changed.
Maggie
And I talk about that as well. When you assume care from a nurse, it’s not that we’re being ugly, that’s just part of professional respect. Are you really hijacking me? Are you really hijacking me? Don’t do that. There’s nothing wrong with the plan of care that you develop with the patient, but now you just have to back that up with an order and that is your responsibility as the nurse. Yes.
Terri
Yeah, yeah, very true. Are there any other things that have come up that.
Maggie
Yeah, absolutely. I do, actually. So I’ll do my best.
Terri
My opinions do not represent every pharmacist out there, but I will do my best.
Maggie
And it’s not specifically about a pharmacist. So in procedure areas, so I just want to talk about procedure areas for a minute, and I do want to encompass the advanced practice nurse, the anesthesia provider, and the Rn, all who have different practices. So for the RN, let’s just say interventional radiology, interventional cardiology. So cath lab, ir, they’re giving the Rn who has conscious sedation privileges, takes the course, does all their requirements, they understand the rules and regulations under the board of nursing is them given procedural sedation. So we’re in, I’m in a procedural area, I’m the interventional radiology nurse or cath lab nurse. I pull my drug, fentanyl versed, I pull it out, I follow the policy, I label it. What, it’s all 100, about two mls.
Maggie
Put that on my fentanyl per the color, you know, we have colored labels and then for the reset it’s orange. I’m putting two milligrams per 2 ML in my respective syringes. I leave the vials there just because, you know, for different departments, billing, accountability, you know, if I open ten vials, you know, it’s a busy case, the vials are there, you come in or another nurse comes in to relieve me for lunch. The case is 2 hours. I haven’t left this room. You know, maybe it’s an hour because I still have some fentanyl reset. I have 25 of fentanyl left and I have half a milligram of her sed lift. Sally comes in, she has her RN, she has conscious sedation privileges. She has taken the same courses that I have. Am I allowed to hand those syringes over to her?
Maggie
I have half a milligram of her sed in this syringe and I have 25 mics of fentanyl in this syringe. Am I allowed? Is the RN to hand that over to another RN in a procedure area?
Terri
Good question. Yes, I would say you’re allowed. The buck is going to stop with the person who removed it. Obviously, if there is something missing, because if Sally removed it and Mary is taking over and we have something missing, we’re going to go to Sally because we know nothing of Mary. We just know that Sally removed it and now it’s missing. So again, I think that comes down to the documentation. I mean, it’s not practical, although you can certainly, and again, this would be based on what your facility’s policies and procedures are. So if the policies and procedures say that you cannot transfer ownership, then you must go through the waste process, and then the covering nurse needs to just remove their own. And that’s it. Discussion is over. If it doesn’t state it, then it’s a matter of that chain of custody.
Terri
And so often, like what anesthesiologist will do, they have the ability in the automated dispensing machine to transfer ownership to each other. The. Yeah, the regular automated dispensing machines, the non anesthesia ones, I don’t think can do that. So that leaves the nurse, you know, kind of exposed. But I would put in the chart, you know, transferring ownership of this to the nurse they took over at this time. Just like you would see for the physician, you know, at this time, if the case was transferred, I just had something like that I was looking at recently, and the removing physician was, you know, dinged with the med. But then I looked to see, oh, he transferred the case to this other physician and he came in at this time because the pharmacy technician had said, this doctor is the one that, blah, blah.
Terri
So when I went to look, it’s like, yeah, I can see the transfer of the case. So I would protect myself from that perspective. And the same goes for when you’re outside of a procedural area. There shouldn’t be those handoffs. Really. Is it that important? You should be administering your med pretty close to when you removed it. Did you not know that your break was coming up or that, you know, something was happening. So you really should complete your transaction. Again, it’s for the safety of the person who removed it. Now there are emergency situations and again, you can see that in the chart. You know, there’s a code going on or something was happening in the ED. You can see that somebody else removed it. In the end, everything matches up and everything is okay.
Terri
So it all worked out and it’s like, okay, I can see you had a lot going on there. The meds were flying. I could see them all. And I understand why you needed help. But along the same lines, if that emergency is now over and there’s something missing, guess who’s going to get the call? The person who removed it. So really restrict those handoffs for true emergencies that are going to be very clear in the chart that there was something going on and it was a team effort. But in the case of a procedural area, I would include the documentation of the handoff handed off the case and hand it off this as long as the policies allow, of course.
Maggie
So I didn’t know that you could transfer over the capability. I presume that, like in an or, the case is open number open under the patient and then just whatever, you know, drugs. I’ve never seen that ability. I don’t know if the RN has the ability to do that now. They should.
Terri
I don’t think the RN does. I think it is only the anesthesia machine. And I have seen it with Pixis. I haven’t seen it with Omnicell. I’m just not as familiar with Omnicell, but I’ve seen it with pixis. And I think it depends on how the physician originally checks out the med, you know, person per, per patient versus. I’m just removing. But there is a way, I know, depending on how they do it, that they can then transfer it to the. To a provider. A new provider.
Maggie
This is a huge lack of education in the nursing realm. I’ve taken conscious sedation classes, I did my thesis and mast my master’s degree on procedural sedation, creating a tool, whether it should be an RN and or anesthesia provider that sedates a patient just because rns are, I feel like, used inappropriately, like ASA different reasons. There are certain patients who should not be sedated by a nurse. So I created this tool. So I’m very intimate with, like some of the education and I’ve been in procedures for a long time. We’re not taught that. It’s kind of like a cultural thing, like it makes sense. Like, why wouldn’t I document in the medical record that I handed over drugs to this other nurse? But it’s one of those things. It’s kind of like a trust cultural thing that handed over.
Maggie
But anesthesia may do that and. But they, in their training, they, when they’re in their orientation, they see the other providers do that. So they mirror what they see. They don’t see. You don’t see nurses do that as a rule. Do I know that? No. I can tell you what, in my practices, what I’ve seen, what I’ve heard, even. I posted this question in one of my Facebook groups. People like, no, you can’t transfer it. Like we’re told, if you draw it up, you’re the only one given it. So. But I don’t. I know that to be different in procedural areas, but what’s the law when it comes down to the Nutcracker and the nurse is standing in front of the board of nursing, which one is, what is the law? What does the board of pharmacy say?
Maggie
What does the board of nursing say? And you touched on some things as well, because if the policy says that you can’t do it, there is no defense. There’s no defense. You just violated the policy, so you have to follow the policy. But when it does come down to the nutcracker, so if you’re called as the pharmacist and you look at. So I pull it out and I give it to Sally and then I write in the medical record that I gave Sally 25 mikes and 0.5, and then that’s not documented after that. But in there she sees it. And for nurses, I’m sure you know this, we can cosign, drug cosign off on, you know, fentanyl drip or an insulin, something that we’re double checking.
Maggie
So that could be a capability that could be created as well, where they co sign it, they come in and take an accepting note as well. I did receive 0.5 and 25 from Maggie, right? Yeah.
Terri
It would better to have the I gave and I received, because now you’ve got. It’s not a he said, she said, because if the initial nurse is diverting, then I’m going to say I gave it to you. And then you’re going to be like, no, you didn’t. And now we’ve got a he said, she said. So are you going to believe the person who said she gave it just because she said it? Because there might be other issues, too. So it is better to have a give and receive and just. But you brought up a good point. It’s, you trust your team, it’s an intimate team that you’re working with. And so now we come to culture, right?
Terri
If I’m a new nurse and I am coming into this team and maybe I’ve been burned before or I’ve seen somebody that’s been burned or I’ve taken your class and I’m just more aware of how I need to protect myself, I’m going to say, Maggie, I’m going to sign this out to you and I want you to receive it and you’re going to be irritated and that’s not going to go very well for me. Being new on the scene right now, all of a sudden, I’m Terri. So that’s a cultural thing that we also need to get people to understand. It’s not that I don’t trust you, I do. But there might be another nurse that comes in that isn’t as trustworthy or has a substance use disorder and I need to protect myself. That’s what it’s about.
Terri
So let’s just develop this process and we just all follow it. And then if we ever do get a nurse someday or a physician, whoever it is that, you know, has an issue, then we will all be covered because, yeah, I’ve seen, you know, I’ve gone into procedural areas to do audits and stuff and, man, procedural nurses, they can be pretty like, what are you doing in here? You know, we don’t need you in here. We’ve got this covered.
Maggie
We’re a team.
Terri
We look after our own. And they wouldn’t be honest with me if they’re life dependent upon it because they are going to stick together, you know, and protect each other. And that isn’t necessarily the right culture that you want because it doesn’t foster that full patient care and really even staff care. If somebody does have a problem, you’re just going to help them, enable them and ignore. Help them to ignore what that problem that needs help.
Maggie
And that should be an opportunity to have better practices because I know in a procedural area that I have to have another, depending on the area, the radiology technologists and the Cath lab do have the ability, where I’m at, if they scrub the case to waste a drug with me, I haven’t left this room. I drove them up in here. The physicians do not have the capability to access the pixis or the omniscient or the techs. Do they pull out? Heparin they pull out drugs that they need for the table. So I, as a rule, won’t leave the room. But there could be times you’re coding the patient, right? That cath lab patient, or that ir patient goes bad, right? And now those drugs that I just pulled, it just turned into a code.
Maggie
Now people were in there, and they’ve left, and now I’m trying to find someone to help me waste drugs. Please, anyone.
Terri
You know what I mean?
Maggie
Or I had to keep drawing up documentation went out the window. We’re all in here saving lives. But now the patient’s intubated, they’re bucking the vent. I don’t have a drip yet. And I’m like, get some more fentanyl. You know what I mean? We just start because, again, we don’t want that patient to excavate themselves. And all of a sudden, we’re like, how much did we give? What was the last dose? How many miles? Sally pulled out drugs. I pulled out drugs because there’s. How many nurses in here, each of us are kind of doing something different, and there’s a lot happening. And at the end of the day, that should be taking as if a pharmacist comes into your environment. And let me just say this again. This should be educational. It should not be, you know, taken as a threat.
Maggie
Now, I say that I have seen pharmacists, unfortunately, who don’t respect nurses. And this is anyone. This is any other industry. This is teachers. This is, you know, it doesn’t matter what it is. And so they’re ugly to the nurses, and they’re, you know, kind of shameful. I’m like, stop. You know what? I just put that person in a body bag. Can I have. You know what I mean? My count is off. And I’m sorry about that. I know that’s inconvenient for you, but you have no idea what I even did in here. You have no idea what’s even happening here. So can I have 5 seconds to work together, collaborating to make some change so that you. You don’t have to come down to my environment?
Terri
Yeah, but that also points to we all, if any investigation that we’re doing or anything that we’re looking into, we need to be open enough to hear, like, what’s it like in your environment? I don’t know what it’s like in your environment. I work in a different situation, and so walk me through it. You know, what has happened here, and learn from that. And then next time the pharmacist knows more, wow. This is the kind of stuff that happens down here. And so things aren’t always going to go exactly as we would like them to go. So understanding. And then the nurse recognizing, because I’ve had some nurses, that it’s like, do you see how it’s a problem that you’re missing an entire vial of fentanyl? And they’re like, no. I mean, I gave it, you know, and it’s just like, no, no.
Terri
You need to see that this is a problem and let’s, you know, figure this out, because otherwise the problem’s gonna be yours. Right?
Maggie
I’m giving you a gift right now because I’m giving you the opportunity to fix this, because the next place that you’re at could call the DEA, and they’re not going to be as nice. And that’s actually their right. And so that pivots kind of like in another question that I do have. So when. When is it’s the responsibility of the organization to alert the DEA? I’ve seen cases where, say, a nurse, even when I was at the board of nursing, that a nurse did divert a drug, did steal a drug. When does it rise to the level that the organization has to report to the DEA? Why do. Sometimes they report it to the De and sometimes they do not.
Terri
Okay. The DEA CFRs are pretty clear. I say pretty clear.
Maggie
You say what CFR is. So the DEA, just so everyone knows, I guess I couldn’t assume that everyone. People know the drug enforcement agency.
Terri
And so their regulations. I’m not sure what CFR stands for. Okay, I should probably know that. But it’s the letters they put before their regulations.
Maggie
Okay.
Terri
There are two times when you report to the DEA, and one is for substantial loss, and that’s where it’s not as clear. They don’t define substantial loss. So that’s a whole other conversation. But you must always report for theft. So it wouldn’t matter if one pill or one vial was missing or ten or 100. If it was due to theft, then you must report. And diversion is considered theft because they’re stealing it. It’s not like it, you know, ended up in the trash with the box because you didn’t see those, you know, sleeve of ten that was up against the side of the box. So there must be.
Maggie
Yeah, I think it’s important to. To really pause there for a second. So I just want to make sure that I understand what you said. So if a nurse or anyone, any provider, not necessarily a nurse. If a physician diverts a drug away from the patient so the patient doesn’t get the medication. That’s considered theft. Those two words are used interchangeably. That’s what you’re saying in that sentence.
Terri
Yes. Yeah. So there should be a report on every licensed professional that has been suspected of. Now, here’s where, you know, it gets kind of confusing if the licensed professional does not admit to it, but the data looks like there’s stuff missing and so you’re kind of unsure. And then this is where facilities now have this quandary. It’s like, well, we don’t know for sure, so we’re not going to report it because nobody wants to report to the DEA. So we’re just not going to report it because we don’t know for sure. And that’s where you get into that. Or they did admit, but they admitted to say three of the incidences, but you have information that indicates was probably more. Then it’s like, well, do I report the three?
Terri
Because that’s what they admitted to, even though I think it was probably 20. And so each facility is going to have to kind of work with their legal team to set a standard as to what they’re going to do. But the regulations read, you must report all that.
Maggie
And then, so the other question is, I’ve also seen where they have involved, and I reference a nurse because that’s what I know intimately. The board of nursing, the board of pharmacy and the DEA. So why involve the board of pharmacy?
Terri
The board of pharmacy has their own regulations, and so I can’t speak to every state, but California is where I’m most familiar with that is a requirement for the pharmacist in charge. So the pharmacist in charge, every pharmacy is going to have that. The buck stops with them. So if I’m the pharmacist in charge and I have a diversion go on. In my hospital, the board of pharmacy can find me liable and I can take a hit on my professional license because of, you know, I allowed that to happen. Of course, there’s other circumstances in terms of how negligent the pharmacist in charge was and the program and the facility and all of that. But every controlled substance must, every pick pharmacist in charge must know where every controlled substance is at all times. That is part of their responsibility.
Terri
And so in those regulations, it states that it must be, loss must be reported to the board of pharmacy. So, yeah, it’s the DEA that requires it. It’s in many states. I’m sure that the board of pharmacy requires it of the pharmacist in charge. And then of course, whatever the licensing agency is, that’s where the complaint itself goes to.
Maggie
So what would the board, if a nurse was diverting a drug, does the board of pharmacy investigate the nurse or do they let the respective board of nursing handle that? What’s the what in that certain position where the pharmacist did nothing wrong, alerted what was part of the, you know, the nurse manager noticed it came to fruition, involved pharmacy. We did an investigation, now it’s being reported out. So the role of the board of pharmacy is in that position in relationship to the nurse would be what?
Terri
Nothing. It is up to the board of nursing to do that investigation. I personally don’t have any experience and this would be interesting for any listeners that have had experience. If the board of pharmacy got involved after they reported that there was an incidence of diversion. And it probably depends on the level of incidents, right? So if there’s patient harm, patient death, and the PIC reports to the board of pharmacy to make them aware, then the board of pharmacy, I suspect, may come in to be like, are you doing your job, pic? What’s going on over here that you’re not keeping track of things? And certainly if the diversion happened in the pharmacy, that would be a whole different matter because now the pharmacy is the one evaluating the complaint.
Terri
But in general, it’s the board of nursing that you will hear from regarding this complaint and the board of pharmacy, it’s more just an FYI, we have this. There were these ten items that, you know, they took. And, you know, what I do is tell the board of pharmacy, how did this happen to the best of our. Without giving too much, because you don’t want to get yourself down the rabbit hole. But we suspect it’s this, we’re addressing this and just let them know that I’m doing my due diligence. You know, we’ve discovered maybe some sort of gap and we’re cleaning it up or that we’ve reported it and they want to know, did you report this to the DEA? Yes, we satisfied that requirement.
Maggie
So I don’t think the nurses realize as well. And let me just speak to my nurse people here, because did you hear her say that the pharmacist. So the pick is, I presume that Ackerman is pharmacist in charge. So the pharmacist in charge is required for all the controlled substances. No, thank you. I mean, so I don’t think that’s, that they don’t realize that. So that’s even more reason for you to be in my environment. Like, where’s the 25 fentanyl sister? Because again, at the end of the day, it’s going to be you. And, you know, I mean, you’re accountable for me. So I think that nurse needs a pause there for a minute because I don’t think that we respect or understand that fact enough to know that you will be called by the DEA and the board of pharmacy.
Terri
Yeah, absolutely. And that rings true, too, for, you know, you’ve got, usually the pharmacist in charge is your director of pharmacy. Usually it’s one and the same. But. And that’s why you can sit in meetings with them and they can take the hard line. It’s like, nope, we’re not. That’s not the way we’re going to do it. That is not the workflow we’re going to do. Or, no, we can’t allow that. Or what have you. And it’d be like, what? You know, it’s like, no, I am responsible for the medications in this building. So they have the right to say, and disagree, you know, even with other leadership that is trying to get to do something else. It’s like, no, this is my license. Yeah.
Maggie
It’s equivalent for a nurse not accepting an unsafe assignment. It’s the same almost, you know, if a bad outcome happens. I took on that assignment. I chose that, you know, I mean, so the onus is on me. So I just wanted to pause there and make sure that nurses understand that piece of it. And then, so the other question is, so it’s recognized they’re sitting there. Is the nurse charged criminally by the DEA? Do you know this? And. Or if it’s recognized, maybe that they have, you know, more likely a substance abuse problem. We have a substance abuse problem. Is that looked at or is the nurse, do, you know, automatically charged by a crime? Because the only reason why the DEA is involved is that it would be criminal conduct.
Terri
Correct. You know, that’s a good question. And I’m not the person probably to answer that 100%. It’s, you know, just as the pIC is responsible for all of the controlled substances in the facility, the DEA holds ownership for all the controlled substances out there. So it’s certainly within their purview to do whatever it is that they feel is appropriate. But I think it very much is a case by case situation. You know, I’ve talked to DEA agents that are very much about the really ultimately they want to get that person help. But again, if there’s been patient harm or death, that is going to go very differently. If there have been complaints at other facilities because, you know, DEA is federal, right? So they know if things have happened in neighboring states or what have you. So I’m sure that comes into play.
Terri
And that’s another important factor as to why that report to the DEA is important and with the person’s name because they know what else is happening. I only know what’s happening at my facility. I don’t have access to all the other information of facilities in town and certainly not out of state, but they can see those patterns. So they have the right to bring those charges, certainly. And they do at times against an individual, I’m sure, certainly against the hospital they do. If they find that is the appropriate way to go. And I’m sure it just depends on a case by case basis.
Maggie
So, and there bears another question. So when you say the hospital will be charged by the DEA, just so I understand that, what does that mean and, or what would that look like?
Terri
Well, they bring a case that, you know, findings, the DEA will produce findings. This is what we found, you know, these ten things, because we have to remember once the DEA comes in, for one thing, they’re going to look everywhere and they’re going to find nine more things. And they’re going to just add them all up. And again, I think it’s a case by case, you know, how egregious was the incident to begin with? Have there been other events and you didn’t report anything? Or are you a hospital that is doing the right things and you’re reporting and you’re taking action and you have a strong diversion program and what have you. So you may have seen, you know, hospitals are being fined in the millions of dollars by the justice system because of what they find once they go in.
Maggie
It’s a bad rabbit hole, sister. It’s bad business.
Terri
It is bad. And that’s why, you know, we need to have solid policies and procedures. All disciplines need to follow, not just nurses, but all disciplines need to follow the policies and procedures. So know what those are before it comes up that you didn’t follow them. It’s important to know what the policies and procedures are because that’s what you’re going to be held accountable to. Deviation from the policies and procedures is a way that we’re going to look to see who is the outlier and who maybe does need to be investigated. And then it is a big thing.
Terri
It’s not just the individual, but there’s ramifications for that pharmacist in charge, for that chief nursing officer or the facility as a whole, their reputation, their financial, you know, now all of this is easy to say, but when you’ve got a professional that’s in the throes of a substance use disorder, they don’t care. I mean, they want to care maybe at certain times, but that need for that next dose is just stronger than everything else. And so that’s why facilities need to have those strong programs that are watching for those deviations. And then hopefully they can intervene quickly, sooner rather than later, and take action that will hopefully keep them out of these, you know, other situations.
Maggie
Yeah, I mean, there, we could go down a whole nother rabbit hole because we should start from this prevention in school because every nurse is assaulted, that’s two an hour. The nurse leaves the profession 30% 1st year, 60% the second year. We’re just not given the tools. And I mean, walk away from the nursing degree. I mean, they’re not going to go to another unit. You just paid for your, you know, child to go to, you know, ut you spent $60,000 on their nursing degree the second year. They’re so traumatized, you know what? They never do nurse again.
Maggie
So we have to go all the way back, because if we don’t want people to have substance problems, then we have to support them, you know, because I can tell you, when I was in the emergency room and I had been a nurse for like three years, four years. And we had a four year old that came in, drowned and didn’t make it. It was in my room, you know, who put that little boy in a body bag, right. You knew who had to follow the policy to tag and bag that little boy? I did. And why? The ER doctor’s yelling us. Why the administration is saying the next patient needs to come in this room while the mom is, you know, crying, she’s. There’s a language barrier. Who came to me? Who gave me any tools? No one. No one. So what?
Maggie
We normalize alcohol way too much. We have prescription drug problems. We have lawsuits right now. And I digress, but you, we have to support my people. You can’t expect me to show up, do these horrible things. If you saw it on the news, right. You knew who spent the most time with that person, right? I did. I did. It was me, the nurse. And so what did you do to support me? What did you do to invest in me? Right. Why did you wait until I have a needle in my arm? Why did you wait till I’m diverting, you know, Vicodin’s because I was 20 and I put someone in a body bag, and I’d never seen a dead body before. So I digress and go down another road, but it has to go back further, and we have to support. Supporting.
Maggie
You know, you talked at the beginning of swinging full back and, you know, coming to closure. You know, we talked about the education with, you know, jurisprudence or, you know, holding a professional license that, in conjunction with some basic tools on self care, have to be provided not just to nurses, but to every provider. Because now you’re at a code with me. Now, you may not be the last one there, but you, too, saw what was there, because pharmacists come to code. Physicians come to codes. We all come to code. We all need tools. So it will be collaboration, and we’ll be working with one another. And we do have to have mutual respect for one another, you know, and understand that. Yes. You know, if I’m upset or whatever, it’s because I call the pharmacy.
Maggie
I’m like, it’s because the pharmacy, you know, the doctor’s yelling at me or the family’s yelling, you know, it’s not personal. And sometimes we do have to put some of that stuff down, but I don’t have the tools. So it’s. We have to collaborate. We have to stand next to another and support one another.
Terri
Yeah. And on that note, there was a podcast that I did with a guest. His name is Mitchell Radin, and there are hospitals that are looking at doing things to address those stressors. And so that was a fabulous discussion with him. They are doing so really neat things. But, yes, that’s a lot of what it boils down to, is dealing with those stressors. So check that out and have your nurses, you know, they’ll be jealous of what is at those hospitals, but they could maybe take those ideas back to their facilities and talk about that. Thank you very much, Maggie.
Terri
This was a great discussion a little longer than we typically, but hopefully it was helpful to some of your nurses to hear it from a pharmacist perspective, from a pharmacist in charge’s perspective and give them a little bit better understanding of, you know, why it’s important for them and for the facility and that pharmacist to do those things. So thank you.
Maggie
Thank you. Thank you. I really appreciate you having me on, because, again, these are questions that my people do have, and we do need to hear other perspectives and your accountability so that I know as well you know, what your level accountability is. We’re all roped into some of this stuff. So thank you. Thank you. Thank you for all you do and having me on.
Terri
Absolutely. Thank you. Have a great day.
Maggie
You too.
