Our Guest: Meg Johnson Hall MS, RN, NEA-BC Founder of Quality Consulting
In this illuminating interview, delve into the world of psychiatric medicine and controlled substance management with a seasoned nurse leader. With a wealth of experience spanning diverse settings, including ambulatory care and acute care, she offers invaluable insights into the complexities of substance diversion and monitoring programs. Drawing from firsthand encounters with employee diversion and her instrumental role in implementing robust diversion programs in ambulatory settings, she sheds light on the unique challenges faced in outpatient care. Moreover, her journey of supporting nurses in recovery provides a poignant perspective on the human aspect of rehabilitation. Join us as we explore the intersection of psychiatric medicine, controlled substance management, and ambulatory care through the lens of this compassionate and knowledgeable leader.
Transcript:
Terri
Hello, everybody. Welcome back to Diversion Insights. My guest today is Meg Johnson Hall. Meg is a licensed nurse who has had a diverse career and has recently started a consulting company. Meg and I are both advisors for Pronexus Advisory, which is a group of independent consultants who really are top healthcare operations and clinical leaders. And with that combined group, they have such a breadth of experiences, and you could probably solve just about any problem you’re experiencing. Welcome to drug diversion Insights, Meg.
Meg
Thank you so much. I’m very honored to be here and excited to have this conversation.
Terri
Me, too. Me, too. Meg’s work with controlled substances is something that she became involved in early on in her career, and she continues to this day. And that is what we’re going to talk about. So take us, Meg, on a little bit of a journey of your career up to this point.
Meg
Great. I will. So, yes, I have a bachelor’s in nursing and started off my career, I joke that I had to do a nine month period in med surg in order to be able to go into specialty. And so I did my. It was supposed to do a year, but I was done in nine months because they needed additional psychiatric nurses at the organization I was working at in Wisconsin. And so started working with a unit that was both psychiatric and chemical dependency. And that had been my love. I discovered in nursing school. So truly enjoyed working with the variety of psychiatric patients that we would get and all the different mental health disorders that they were struggling with, from depression to schizophrenia to chemical dependency to a whole variety.
Meg
So I knew I kind of reached my area of passion that I really loved to do. And then shortly, probably two years later, I moved out to Arizona and started working in psychiatry there. And absolutely loved that I was working on a mood disorders unit to begin with, became the assistant nurse manager, and then became house charge and started doing psychiatric consults at the emergency department, doing assessments with the residents that were on call. And that was, again, just a phenomenal experience. Worked with both psychiatric patients and, again, chemical dependency patients, and then moved into a manager role. And the unit that I had was a 72 hours hold unit for a county, and, again, truly enjoyed that work in working with the less privileged population and seeing some of the unique challenges they faced during that position.
Meg
One of the topics that came up that I got involved in was, how do we manage when we discover either one of our staff are impaired on the job, or we suspect that they’ve diverted medications, control substances from our inpatient unit. And so worked with some employee health colleagues and some nurse, other nursing leader colleagues, and some clinician colleagues and kind of developed the new system for how were going to manage if a employee was impaired. And I actually had two of my employees during my time there that actually went through that investigation process and then ended up inpatient treatment. One had relapsed and one was a new diagnosis.
Meg
Also worked with the state board while I was in Arizona and actually became a counselor for the state board group that they had first to support nurses that were chemically dependent, and we’re on some restrictions with our license. So I ran that group for about three years and learned so much, you know, about what, how impactful this disease is and how it really works with nurses and what drives them to actually, you know, divert substances from their work or come into work impaired. It’s just such a powerful disease. And then later on, I actually ran an adolescent unit, inpatient, outpatient, and residential, for both chemical dependency.
Meg
I was a program director for that, and then later on moved to Minnesota, started working for Mayo Clinic, and actually worked in their chemical dependency unit there for a while and then went into other types of leadership, but maintained that passion later on. Working in Arizona and Colorado, I continued to work on chemical dependency project, was working with a health system that had twelve different organizations in that health system, and they had done a really great job of developing a controlled substance management program for the hospitals in that system. But the ambulatory care and hospital based outpatient areas were kind of disjointed. We had different processes with each of the different organizations. Some really didn’t have much of anything for ambulatory care.
Meg
So embarked on a but a year and a half long project with my pharmacy partner, and we created the organizational wide control substance management program. And that was a challenge when you have twelve different organizations, all with their own processes, their own systems, how they work with pharmacy, what they have for storage, those kinds of things. It was a real challenge, but were really super proud of the work that we created. We created new policies, new work standards, a resource webpage, a monitoring system where we would do audits on an intermittent basis. And most of the ambulatory cares do not have PCs or any kind of system like that. And so, you know, we really had to work with them individually to find out how to safely store those substances and also do a lot of education.
Terri
Wow. There was a lot in that introduction. Should I be taking notes here? Just to ask some questions? All right, so let’s go. First of all, it’s great that you had a passion for the psychiatric space that must be an extremely difficult and frustrating space.
Meg
Yeah, I would say it’s a little frustrating, but again, one has to, you know, when you come from a medical background, you figure, okay, I can do this surgery, we can do this rehab, and then this person returns back to normal and boom, we’re done with them. That isn’t the case in psychiatry most of the time, there’s short term depression or other kinds of things, PTSD, but there’s other things that really need long term care. It’s more like managing some of your chronic cardiac positions or situations or chronic neurology diseases. They have to have that continued care, and that can be troublesome because you expect to cure them by the time they leave and you don’t, it’s really helping them to manage the symptoms the best that they can and have the best quality of life.
Terri
Right. Well, and as long as you have people that aren’t, you know, mixing that with other substances that make the disease state worse or they’re compliant with whatever medications are helping to control things, I mean, I think a lot of them, as you said, the underprivileged or you might be homeless or just people that don’t manage it well on their own.
Meg
True. And I think the newer thing that we’ve struggled with recently is a lack of access to care. You know, whether that be an insurance issue or whether it just be a resource issue. You know, many of the psychiatric visits and psychiatrist visits and are out anywhere from one to three, four months. So, you know, you look at that and somebody’s in a psychiatric crisis, they can’t wait three months, you know, and even our inpatient care is now, you know, 24 to 72 hours. It’s really difficult to stabilize somebody in that short amount of time.
Terri
Yeah, absolutely. Okay, let’s talk a little bit about your work with, in Arizona with the board of nursing and the counseling there. You said you gained a lot of insights on nurses in particular and how they get to that point and what they’re thinking. Can you share a little bit about some of what you learned doing that?
Meg
Yeah, it was really powerful to run that group. I understood the disease, and I understood the power of the disease, and then it drives you to do some things that you wouldn’t do if you didn’t have chemical dependency or addiction of some sort. But I really got to see almost the day to day struggles in and visualize that much clearer as I talked with these nurses on a regular basis and heard, you know, oh, it was so difficult because I’m just starting back to work now, and I have access to the pyxis, and, you know, I’m supposed to get somebody to come with me when I get out of control substance out of the pyxis, but many times there’s nobody around.
Meg
So do I let my patient just suffer for a little bit longer, or do I break my rules and just go ahead and get the control substance and give them the relief? So it gave me a lot of insight about how we need to better structure these experiences for these nurses when they return to work after going through treatment and some of the day to day struggles that they really face and the judgment that they face sometimes it’s very painful for them to have to admit that they have this disease and they have to rely on someone else to oversee them or sign off for them or those kinds of things. It’s very much hard on their dignity.
Meg
So I learned just a lot about that side of it, not so much the treatment side of it, but the human experience of going through this and that when they get to this point, then it’s just, you know what? It’s better if I just go get high, you know, and am I going to get that from the street or am I going to get that from, you know, my system? And so it just, it’s a coping mechanism as well as a disease, and we put them in situations that they have to cope with extra stress from what they’re already dealing with, family and finances and those things. So it was very powerful.
Terri
Right. So I’m sure that shaped to some extent your work that you’ve done with people on a reentry program and what those processes are. So what do you find? I mean, we want to keep the confidentiality, but obviously, if somebody needs to remove meds with them and oversee them, that confidentiality is gone. I mean, everybody knows, you know, what the deal is. Right. Even if you don’t say something.
Meg
Right.
Terri
So what are your thoughts surrounding that? Well, first, I guess I should ask, are you a believer in reentry after treatment and recovery, and what are your thoughts on those parameters? And then what do you think is a good way to do that? Reentry so that we preserve their dignity but also make sure that our patients are safe and we reduce liability for the institution as well.
Meg
Right. Yeah, I think to me, it’s a very, I’ve reentered many people over the years, and I think it’s a very individualized experience as far as what we do and what is available within the organization. So some of the organizations that I’ve worked with, they’ve had much lower risk opportunities for people to reenter back into work, you know, whether it be case management or care coordination or working in maybe more of an ambulatory or urgent care environment as that initial year of, okay, let’s get you stable. Let’s make sure you’re feeling comfortable being a nurse again, and then we can reintroduce some of those things. People that really love inpatient kind of doing some of that case management or discharge planning kinds of work gives them an opportunity or doing admissions. So there’s always a creative way.
Meg
I think one of the most important things is that their leader is their educated and understands the disease process and understands both the advantages of this and the disadvantages. I think with the recruitment and retention challenges we have now, I don’t know that we have much of a choice but to be open and receptive and creative in designing some sort of reentry program for individuals that have gone through this, provided the board allows that. The board of nursing. But I think that’s really an important piece, being a partner with a nurse on this saying, what do you feel comfortable with?
Meg
You know, and we always had the nurse share with the other nurses that, you know, I have some restrictions on my license right now, and so this is what I need, rather than us going and having a staff meeting and saying, okay, Susie’s coming back to work. And by the way, you know, she’s an addict, and so you always have to sign for her. We can’t. We can’t do that, and that’s not the right thing to do. So we say, you know, how about if you just work on this wing or with this clinic, and then you tell the people you know that are, that you’re just working with on that wing, that you need help and you need support when you sign out control.
Terri
Substances, were most of them willing to do that? I mean, I’m sure it’s probably kind of an awkward conversation for them.
Meg
You know, they really want to come back to work. Most of them, I won’t say everyone, but most of them want to come back to work. And so having those really powerful, meaningful conversations before they come back to work about, you know, making sure they’re ready, that they feel ready, and then developing a plan with them not for them on, you know, this is kind of how we’re going to look at. Here’s the choices, here’s the options. You know, how do you want to do this? And then letting them know for confidentiality reasons I can’t share. You know, that you’re. That you have struggle with addiction, that you have to be the one to share that information. But I can help support you. I can help structure that.
Meg
If you want me to be there when you talk with the staff, you know, the couple staff that you want to work with, I can do that. So we’re really offering whatever kind of support you can in that reentry program.
Terri
Do you find that it’s maybe part, another piece of therapy slash healing recovery process that they be able to express that this is what I need because right now I have restrictions. It’s kind of saying that out loud is part of the recovery process.
Meg
I do think so. You know, it’s a difficult part. You know, it’s kind of like when they have to talk with their families and explain, you know, the next step then is kind of talking with some of your co workers and, you know, I even did role playing with them and rehearsing with them on, you know, how they were going to say that and what they choose to share because they don’t have to share a lot, you know, and some wanted to share more and some said just, nope, I just need them to know that I have a restriction on my license, a temporary restriction, and that these are the things I need help with.
Meg
And so really kind of helping them customize it enough so that it meets the needs so they do get the support they need, but yet it doesn’t make them feel so vulnerable, you know, and almost violated. Right. So. Yeah, but it is definitely a step in healing. I agree.
Terri
What have you found in general is the response of the peers that now know, are they supportive? Are they judgy in general? I mean, it varies, I’m sure.
Meg
Yeah, it does. In general, I think most are quite supportive. You know, I’ve ran across a few that’s like, oh, no. Oh, no. That risks my license. I’m not having anything to do with it. Or they become so controlling that it, you know, the person feels like they have somebody hovering 24/7 over them. But in general, I think if the leader is educated and understands and is supportive, generally most of the staff will also be supportive.
Terri
Okay. And what do you find is a good length of time that somebody, I mean, obviously, a lot of it is driven by the board and their requirements or the treatment, you know, the recovery monitoring system, and they have their rules. But do you have experience with people? I mean, okay, so you’re doing this for one year, two years, and then now six years down the road, you know, I’ve heard of relapse then where you think you might be in the, I mean, how do you know, again, it varies, but.
Meg
Right.
Terri
What point do you think the facility can feel confident that, all right, been there, done that, we’re good?
Meg
You know, I think, and again, a lot of this is individualized, but, you know, I think if they’ve been able to go one to two years, you know, again, depending on the stipulations from the board, and they’ve, you know, typically the board also has them coming in for random drug tests. You as an employer can set that up as a part of your agreement as well, to be able to do random drug testing. You know, I think you, again, you get to see how are they living the recovery, or as I call, you know, are they just, are they living sober or are they living in recovery kind of thing? And so are they really owning this and understanding this and really developing that trust with their peers? And most of the time, I think that happens.
Meg
But, you know, again, part of the education with everyone is there is always a chance of relapse. You know, and we’ve all had employees that have relapsed. And so again, the organization kind of developing and even letting that person know when you come back, okay, you know, if you relapse, then, you know, we’re not able to take that risk anymore or we’re able to take it, you know, depending on these circumstances. So, yeah, it’s always, there’s always that level of anxiety and I don’t want to say suspicion, but always a little questioning of, you know, is this person, after a year or whatever, really ready to go solo?
Terri
Yeah, well, I think it’s.
Meg
Well, go ahead. I think the other part of that is making sure that the organizations have good systems in monitoring control substances and doing the audits or running the reports, you know, depending on what their system is, because then you will catch it in addition to just being aware of the behaviors of how that person might look different. So a big component that is having the structure and having the education.
Terri
Yeah. And perfect actually lead into. What I was going to say is that it wasn’t too long ago that I spoke with somebody where the diversion monitoring person found out, well, there was a situation where there was some concern and the mentor had actually started to notice a few things, but did speak up in say anything. And then it wasn’t until something else happened that they have a conversation and say, yeah, over the last month or so, I had noticed it’s like, well, my goodness, this is part of your responsibility. Why did you not say something? And so that comes back to that kind of educational piece, I guess, which, I don’t know, maybe the mentor then is like, oh, I don’t want to say anything. Maybe it’s nothing, but maybe it is something.
Terri
I mean, they have to feel comfortable to say, I have noticed some changes.
Meg
Yeah, I think that’s a really important point which ties into culture, is creating that culture where people are comfortable saying, you know, I’m a little worried about this. I’ve seen this and this, and I’m a little concerned, you know, where do we, what do we do next kind of thing? Or, you know, talking to the leader. The leader runs some additional reports or does some other, you know, checking if it’s paper system, you know, to really kind of see. Okay. And just being aware and then having that honest conversation with that individual saying, we’re seeing these changes, you know, can you share with us what’s going on?
Terri
And that needs to be part of the whole reentry process. I mean, many facilities, we learn as we go, right? We don’t think of something and then something happens to, and it’s like, oh, we didn’t know what to do there. So let’s update our processes because now we’ve learned from that. But that does need to be a piece of, you know, what do we do? Do we send them back to the monitoring program? Who’s going to do the assessment, right. To see if there’s something else going on? How do we handle that?
Meg
Yeah. And many times the boards will be very specific about what they’re, what they do if someone relapses. And sometimes as an organization, it’s out of your hands, you know?
Terri
Sure.
Meg
Yeah.
Terri
But really not sure that they relapse. They’re just like, you know, you’re acting a little funny.
Meg
Like, you know, that’s an important part of building into your program, into your reentry program is the ability to do random drug tests so that if you do say, oh, I don’t know, you know, so and so is looking a little different, acting a little different. There’s been a couple questions. You know, let’s just pull a random test.
Terri
Yeah, sure. That could be the first level of. Yeah. Seeing what you see. Yeah, that’s a good point. Okay. You mentioned you did some, I think, the twelve system that you worked, the twelve that was ambulatory, correct.
Meg
Ambulatory and hospital based, outpatient.
Terri
Okay. What do you see are differences inpatient versus ambulatory or outpatient? Do you find that there are quite a few differences.
Meg
Huge, huge differences. You know, number one, there’s not really, in many systems, there’s not that commitment to have a really nice control substance program in ambulatory because the perception is they don’t have control substances. Well, that’s not true. You know, we had, I think, between 50 and 60 clinics that had controlled substances out of 112. So that’s, you know, that’s a significant amount. The other piece that, you know, we’ve noticed is sometimes, you know, years ago, and, you know, those of us that have been in healthcare for a long time, years ago, most of the nurse leaders that came into ambulatory had worked inpatient. So they really had that full understanding of how tightly you needed to control substances and what you needed to do to manage it.
Meg
Now we’re seeing brand new nurses with maybe a year of ambulatory experience or maybe a little bit of home care or nursing home experience coming in and being leaders in ambulatory. They’ve never worked in a hospital system. They don’t really fully understand, number one, what are control substances and what are the DEA requirements that we have to follow in order to do that? That’s one of the big learnings we had, is that the majority of our nursing leaders did not understand what a clinician registrant was, didn’t understand that you need to have a double lock, didn’t understand that you need to do inventory, keeping the paperwork, you know, the invoices that come with the control substances. The other challenge in ambulatory, I mean, one, we’re getting more and more procedures done. We do have ambulatory surgery, and most of the time they have pyxis.
Meg
Not everyone does, but many times they do our endoscopy areas, most of the time have pixis, but again, not always. And then a lot of our surgical areas in ambulatory that may do dermatological surgery, may do urological procedures, other things like that, don’t have PCs. And then a lot of other areas where they’re, you know, it’s not as significant, maybe, of a controlled substance like testosterone. They don’t have pyxis at all. And many times, the periods that have Valium or Ativan, those, they don’t have pixis either. So that creates a whole. There’s not that tracking. There’s not that record of, you know, Meg signed in and took this, and we can see it in the pixis that she did, and we can run a report. There is no such thing. So you’re reliant, really, on working with them to create a double lock system.
Meg
And then again, we’ve had places with double lock systems that they throw the keys in the. In an open drawer at night. And I know you’ve seen a lot of those same things. And so it’s really huge education from the top leadership on down, as far as what the fines are for this, what the risks are for our staff, and what the risks are for patients. And so it’s. It’s really just kind of almost like an awareness across the country in ambulatory care that this is something you need to be compliant with and you need to be aware of and your staff need to be educated on.
Terri
Yeah, well, I think a couple of things there. Do you think part of it might have to do with one, like you said, maybe not as many drugs, but also there’s no, or very little pharmacy oversight because they’re not the registrant. So, you know, you get a pharmacist in charge, and we are usually pretty,
Meg
You do this, you know, we’re watching.
Terri
But when pharmacy isn’t the registrant, they may have some oversight just to kind of. Because it’s part of the system. Right. But it’s not where the buck stops here. That’s.
Meg
Yeah, that’s a really good point. We found that, you know, some of our sites were getting it from our pharmacy, but our pharmacies have limits on how much they can support. Believe it’s depends on the pharmacy. But 5%, approximately, is what they can distribute out to ambulatory sites. And so with us getting more and more controlled substance in ambulatory care, many of the sites, the pharmacy was no longer able to support them. So then they were going to outside vendors. And, you know, the outside vendors don’t have the same. Well, the same system as far as transportation and verification and those kinds of things. So were having some really interesting situations where controlled substances were just left on a dock sometimes, you know, with no signatures, no anything.
Meg
So there’s just a lot of education, especially, like you said, if pharmacy is not involved in that, to make sure that we are tracking that we’re getting the chain of custody and getting all of the information that we need to and the safeguards.
Terri
Right.
Meg
Yeah.
Terri
And so if they’re not the registrant that is really in charge, then, as you said, it’s getting probably the physician who is the registrant really engaged and understanding, as you said, what are the ramifications of having a registrant?
Meg
Right. And there’s a lot of lack of knowledge there, too, that clinicians just get asked to you, will you just sign off on this form? And so we can order control substances? And they don’t understand the responsibility that they have when they do agree to be the clinician registrant.
Terri
Yes. And do you think there could be a bit of. They don’t understand just because they don’t know what they don’t know. But do you think there might be a little bit of. No one would want to do this if they knew, so let’s not make a big deal about it from the institution’s perspective. We just need a doctor to be the registrant.
Meg
I agree. I think there’s definitely, number one, they’re busy, and that is not their focus is, you know, how to manage controlled substances. And so they really don’t take the time to research that to learn. And then I think there’s also that thing of, you know, we just need them to do this. So let’s not get into the weeds of the level of responsibility that this actually is and the risk that they take on by being the registrant.
Terri
Right. Yeah, yeah. No, it’s, they just feel flattered we asked you, but don’t figure out what involved. You know, I think the other thing, too, is typically, it’s a much smaller group of people. Right. And so even an inpatient, you see that in a procedural area, they’re kind of that family. They’re like, we got this, you know, we take care of our own. But I would think it’s maybe even more in an outpatient ambulatory surgery center type of a situation where, you know, we’re family. We don’t have to have necessarily all of those official procedures.
Meg
Right. Because we trust each other. We’re close. Yeah. We work together every day. Yeah. And I think that’s definitely a part. And, you know, we have non clinical leaders that are clinic managers. You know, they’re business leaders. And so there’s not that knowledge again, and understanding of that. And like I mentioned before, we have nursing leaders that have not worked inpatient and may not understand, even if they have, that this transfers to ambulatory as well. And then we have clinicians who aren’t really taught or understand the responsibility to. So it’s a little bit nerve wracking, I think, to see some of the processes and just again, and the lack of understanding it’s no one’s fault. It’s just that, you know, that isn’t. That knowledge isn’t there.
Terri
Well, and on top of that, even in the inpatient side, many people don’t understand that diversion happens and that a healthcare professional is just as susceptible to a substance use disorder as a non healthcare professional. And so you’ve got that education piece on the inside, on the inpatient side, but then you translate that into ambulatory, that doesn’t have the pharmacy oversight to make you paranoid, and then a registrant that doesn’t particularly understand all of that and potentially no automated dispensing machines. And we’re all a family, and nothing has ever happened. Right.
Meg
To our knowledge, in our clinic. Yeah, they might have happened somewhere else, but it wouldn’t happen here.
Terri
Yeah. And so you put all of that together and you just do your thing until something happens. And now you need to change how you’ve been doing things.
Meg
If you find out that something happens.
Terri
If you find. Yeah. Once it becomes clear that, oh, that’s a problem. And then you become very reactive. Right. But.
Meg
Right. And realize having that investigation structure in there, you know, who’s on the investigation team, how does you know? That’s one of the things we created was a worksheet for our. Our leaders in our clinics because they were calling us all the time. And it was many times just that, you know, Jane had given this dose of medication, but hadn’t made it back to document, finished documenting, or hadn’t documented in the chart, but documented in the control substance. And so, you know, it’s. It’s really helping them, guiding them through that first level of investigation of what has gone in. In our clinic and where could be areas that I look to see if this truly is missing or nothing.
Meg
And then, you know, if they find that, no, I can’t solve this problem, then who do you outreach to and who helps you walk through that investigation?
Terri
Sure. Yeah, that makes sense. And then there’s always the practice versus. For practice versus diversion. How do we sort that out? Which sometimes it’s not always clear. Many times it’s not always clear exactly what’s going on. Yeah. Can you share with us, you mentioned you had a couple of diversion situations while you were in leadership. Can you share anything about either one of those cases?
Meg
Yeah, in one of the cases, we had two different ones. One of them, we discovered that some Ativan was missing when they did the count at the end of the shift. And so, you know, we. We did our usual unit based investigation to see if we could figure out had somebody forgotten to sign it out or cross checking the charts versus the control substance record. And we found out there was not anyone that had done that. So what we did was we actually. Then it was kind of having some conversations with the staff, and nobody could go home until we figured out this Ativan situation and then going through and having conversations with people.
Meg
The interesting thing was, were partway through our conversations, and the unit clerk that we had, I went out to ask her to call somebody for me, and she was sound asleep on her phone, and it was ringing. I mean, sound asleep, passed out kind of on her phone, and her head was laying on the phone, and the phone was ringing, and she wasn’t obviously answering it. And so woke her up. Yeah, exactly. Woke her up. And, you know, took her to the office and said, you know, can you tell me what’s going? Because sometimes there can be medical reasons for that. Sure. You know, so you don’t want to assume. So.
Meg
Had some conversation with her, and through the conversation, discovered she was having some real challenges in life and said, well, you know, based on what’s going on, you know, with you today in the. In the unit, I need you. We need to walk over to employee health and have a drug test. And our policies and all that supported everything that were doing. And so we did. And it came back with. With positive for drugs like Ativan. And so, you know, then it was having the rest of the conversation. Another time, it was a nurse of.
Terri
Mine, before you tell about the other time. So that was a unit clerk.
Meg
Right.
Terri
So she did not have access to controlled substances. Right. So somebody. Was this not an automated dispensing machine? It was cabinet somebody. The keys were just out. She was able to get to it. Okay.
Meg
Yep. Exactly. And that was part of our investigation, was figuring out how did she get it. And so one dose she actually got because a nurse left it sitting in a little cup and asked her to watch it.
Terri
Oh, okay.
Meg
And when the nurse came back, she said, oh, I’m sorry. It dropped on the floor, so I threw it away. I flushed it because I accidentally knocked it over working on this chart. And, you know, we’d never had any suspicion. The other one, she nurse, had actually left the cabinet unlocked for a couple of minutes while she went. It was a kind of a behavioral code situation, and she saw that opportunity to go in and. And help herself.
Terri
Okay. All right.
Meg
So, yeah, you just. You never know. You never know.
Terri
Yeah. Well, it’s a good reminder, I mean, you know, those in the space know that it can be people that don’t have access, quote unquote. And we need to be mindful of that.
Meg
Absolutely, absolutely. The second situation was individual that was in recovery, and was very honest and open about being in recovery, had not, historically, ever diverted from work, was a nurse. And so that individual we had, this was an adolescent unit, and we had an adult unit. They covered kind of both. And so we had a couple behavior codes where we had to actually give Im medications held all in Ativan. And then what we discovered there was we had the multi dose file of Ativan, and that individual was very good and had actually been withdrawing. Anytime he had to go in, he would always offer to go in and do the prep the meds for the coat. And what he was doing was injecting sterile saline back into the Ativan vial, and then he would use the other Ativan vial.
Meg
We had two open, which is not our normal practice. He would use the other one for the patient and then continue. So it wouldn’t be until we got to the next vial or somebody else would grab that vial, that they would realize, wait, this didn’t have any impact on the patient. Why not? And then he was filling syringes for himself.
Terri
Interesting. Yeah. So it didn’t point back to him, obviously, because anytime he was involved, the meds seemed to work.
Meg
Right.
Terri
Interesting. Okay. Yeah.
Meg
That was one of the things I really learned, was how creative, even for the drug tests. You know, we had individuals that would. That would find a way to, you know, have their child get a specimen for them, and then they would figure out a way to get that actually into the. To the drug testing cup. So very creative in finding out ways. Again, that’s the disease speaking, trying to help them maintain their. Their way of dealing with life.
Terri
Right, right, absolutely. Okay. If you could give people that don’t really have a process, a good drug diversion program in place, a couple of pieces of advice. Is there anything in particular that you would say is the most important thing or that they really should think about and consider that they might not normally think about right away?
Meg
Yeah, I think the first thing is making sure that everyone is educated and that we kind of break through their denial that it can happen anywhere. It isn’t just an inpatient or a pharmacy problem. This can happen anywhere. So I think doing the education with the staff of what to look for, how do we manage those controlled substances safely? How do you safeguard them? Everybody has a different system, but making sure those drugs are safeguarded from the time they arrive at your door until they go into, you know, a patient’s arm or into a patient’s mouth. How do we safeguard that? And having, you know, a really established process to do that, as well as a really fair, thorough investigation process.
Meg
And then again, I can’t say enough the education that’s needed on what those FDA guidelines are, what the DEA guidelines are, how do we make sure that we’re in compliance? Understanding the record keeping. So those kinds of things are just really critical.
Terri
Sure. Okay. Fantastic. All right. This is great. Thank you. It’s a lot of. A lot of great information. You’ve got a lot of experience in your background with this, and it was good to learn from you and hear what your experiences have been. Thank you.
Meg
Yeah. Thank you for having me. As you know, in nursing, it’s just something we encounter on a regular basis. And like I said, my background has been some inpatient, but the majority, the last 30 years has been in leadership and in ambulatory care. And so that’s really kind of my. My area of expertise and in the area that I really focus on that needs, because, again, we’re adjusting as. As we get more and more procedures and more acuity in ambulatory care, we have to recognize that times are changing for us as well. All.
Terri
Yeah, absolutely. Okay. Thank you. Thank you very much for your time, Meg.
Meg
Absolutely. Have a great day.
Terri
Thank you. You, too.
