1. Section Editor(s): Fulton, Janet S. PhD, RN, ACNS-BC, FAAN

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Stories about addiction to medically prescribed drugs seem to be omnipresent and involve the entire spectrum of social class. Nurses are not exempt, and for many years now, state nurse associations have worked with licensing boards to develop and maintain highly effective peer assistance programs for impaired nurses. It happens, but we have systems in place to address it. Yet, a local public radio story about drug diversion among healthcare workers piqued my interest as I was driving to work ( The report stated that the scope of the problem is not known because some facilities do not report drug diversion. So as to not assume anything, let us be clear: Drug diversion-using prescription drugs for another, usually recreational purpose-is a felony crime. Drug diversion occurs in healthcare facilities when providers, nurses, and others with legitimate access to the drugs for patient care purposes steal the drugs for personal use. Regulations require reporting of instances of drug diversion. But instead of reporting a crime, the story noted, "facilities"-that would be those persons in charge, aka administrators-choose to discipline employees themselves or ignore the issue altogether. The police position was that this approach is not helpful to the overall effort of addressing drug diversion. The story quoted John Burke, president of the National Association of Drug Diversion Investigators, as saying "I think the majority of non-reporting is done deliberately." Really? Why cover up a crime and ignore reporting regulations? Burke continued saying, "And, I think it has to do with media. They're concerned about media attention, lawsuits, liability." Holy smokes! It is all about image, and here I am thinking it is all about patient safety.


It is incumbent upon care facilities to address drug diversion, including nurses, and to guide them into existing peer support treatment programs. Yes, it is difficult to do. Things can get messy. But it is the responsible thing to do. In addition to putting patients at risk, the accompanying work behaviors of a drug diverting nurse often are disruptive to the work environment. Coworkers generally know something is off kilter. In the absence of a culture that promotes safe reporting of suspicious behaviors, coworkers look the other way. Frontline supervisors may find little support in bringing forward concerns that could lead to unwanted media attention. To be fair, there are conscientious, responsible administrators and systems with excellent employee assistance programs for intervening in situations of drug diversion and impaired providers, but apparently, there are gaps.


The ultimate story of the failure to report a crime is detailed in Graeber's book, The Good Nurse.1 Charles Cullen, a registered nurse, is implicated in probably hundreds of hospitalized patient deaths over 16 years in multiple hospitals, although he has been convicted of only a few. His actions were criminal and prompted by motives known only to him. Part 1 of the book details Cullen's personal story-his childhood, time in the Navy, nursing school, marriage, and work in various hospitals. Part 2 of the book details the investigation into his criminal behavior. Most disturbing about part 2 is the failure of administrators to address a suspected problem employee and report poor performance and, once a criminal investigation began, their being uncooperative with, even lying to, police detectives. The story was told on the CBS News's program 60 Minutes and can be viewed at and The author, Charles Graber, was interviewed on National Public Radio's Fresh Air show and can be heard at


It takes courage to nurse. Nurses are taught to be patient advocates, so they must also be helped to be in touch with their inner vulnerabilities and to develop courage. Without courage, there can be no advocacy. The Institute of Medicine's report The Future of Nursing2 calls for nurses to assume greater leadership in advancing healthcare. It is apparent that there is an urgent need for system-level leadership to ensure that criminal behavior is confronted, reported, and addressed-leadership that models courage. Criminal behavior is a patient safety issue, but it is not an error, lapse, or unintentional act resulting in unintended harmful consequences. It is wrong, illegal, and professionally unethical. No nurse, no administrator should fail to report criminal behavior. In the 60 Minutes story, the New Jersey Poison Control Center was involved in reviewing suspicious events at the time they occurred, and the center's director had urged the hospital administrators to report the incidents to the police. In the interview, the center's director agreed with the interviewer that subsequent deaths, at least 5 deaths, could have been prevented if administrators had not waited 3 months to take action.


Forget the marketing-created image-the cute slogans, touching television commercials, the attractive logos on billboards designed to attract patients over a competitor's hospital. A great healthcare system, one with courageous nurses supported by responsible administrators, is the one with the highest rates of reporting employee criminal behavior.




1. Graeber C. The Good Nurse: A True Story of Medicine, Madness, and Murder. New York, NY: Twelve, Hatchette Book Group; 2013. [Context Link]


2. IOM (Institute of Medicine). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: The National Academies Press; 2011. [Context Link]