Waste Not Witnessed
An automated dispensing report shows that one of your 45 RNs on a 30-bed surgical unit removed hydromorphone at roughly three times the peer median, with six of fourteen shifts showing "waste not witnessed." She is a 12-year employee, a former preceptor of the year, recently divorced, and has been volunteering for extra night shifts. Last week the charge nurse found a patient's PCA tubing disconnected and the patient reported no relief, while the nurse had charted pain 2/10. Your HR business partner says, "We can't act on statistics alone," and asks what you want to do.
1. What are your next steps in the next 24 hours, and what must you not do?
Read the worked answer
Patient safety outranks the investigation.
Do:
- Assess current patients first. Reconcile the PCA, review pain scores against objective signs, examine the pump and tubing, and have another nurse reassess her assigned patients tonight.
- Remove her from patient care pending evaluation, framed neutrally under existing policy ("administrative reassignment pending review"), not as an accusation - this protects patients, her, and the integrity of the review.
- Notify HR and employee health immediately, and follow your fitness-for-duty and drug-testing policy exactly, including chain of custody. Timing matters; a delay can invalidate the testing.
- Secure the evidence - preserve Pyxis transaction and waste records, the pump history, and the MAR. Have the charge nurse's observation documented in writing the same day.
- Escalate per medical staff/peer review and quality structures as your bylaws require, and confirm with risk management.
Do not:
- Do not confront her alone or accuse her of impairment. You are not diagnosing; you are initiating a policy process.
- Do not access her medical records, EAP records, or test results beyond what your role formally permits. That is a confidentiality violation and can taint the case.
- Do not discuss it with staff beyond "she is out on administrative leave."
- Do not let the HR partner's hesitancy stall patient-safety steps. "Statistics alone" is a fair standard for discipline; it is not the standard for reassignment pending review.
2. Separate the systems problem from the individual problem. What standard of proof applies to each action you might take?
Read the worked answer
Run four parallel tracks with different thresholds - conflating them is the most common manager error here.
| Action | Trigger / standard |
|---|---|
| Immediate reassignment from patient care | Reasonable suspicion - low threshold, safety-driven, reversible |
| Full investigation (audit, interviews, Pyxis review) | Gather data; no finding yet |
| Discipline | Preponderance / just-cause standard per policy and any union contract; due process required |
| Board of nursing report | Varies by state - verify. Many states require employers to report when there is reasonable cause to believe a nurse is impaired or has diverted; some mandate self-report deadlines |
Systems side - genuinely examine these before concluding it is all her:
- Is waste-witnessing on this unit routinely skipped, by many nurses? Run the same report for all 45 RNs. If 40% show missing witnesses, you have a normalized at-risk behavior problem and singling out one nurse is both unjust and ineffective.
- Is PCA verification and pain reassessment reliably done unit-wide?
- Is the workload on nights such that double-checks get skipped?
Individual side: repeated, outlier-level divergence in a pattern the rest of the unit does not share is not human error. Under a just culture framework, human error is consoled, at-risk behavior is coached, and reckless behavior is sanctioned - and diversion sits well beyond at-risk.
Be careful with the personal history (divorce, extra shifts). It is tempting narrative and it is not evidence. Support resources should be offered to everyone, not selectively deployed to support a theory.
3. What do you tell the unit, and what do you never say?
Read the worked answer
Say:
- A brief factual statement: a colleague is out on administrative leave, patient care is unaffected, and the unit is fully staffed for the next shifts.
- A restatement of the standard, not the case: every narcotic waste requires a witnessed signature, no exceptions, and here is who to call when you cannot get a witness.
- The process expectation: this will take time, decisions will be made through HR and the appropriate review structures, and you will share the outcome when you can.
- A general reminder of the employee assistance program available to all staff - no names, no connection to this event.
Never say:
- Any suggestion that she diverted, is impaired, or is being investigated for a specific act. If the investigation clears her, that statement is defamatory and the unit will remember who made it.
- Anything about her divorce, her extra shifts, or her personal life.
- "Nothing is happening." Staff can see the schedule and they will fill the silence with worse than the truth.
- Details of a disciplinary outcome beyond what policy permits - this is her personnel record.
Anticipate the backlash. A 12-year, award-winning nurse generates loyalty. Expect "she's a good nurse, you're out to get her." The response is not defensiveness but consistency: the same process would apply to anyone, and here is what it is. If the audit shows that waste-witnessing is lax across the unit, say so publicly and fix it - otherwise the team will conclude, correctly, that the rules are enforced selectively and only when someone is suspected of something worse.