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The alteration of drug logs to mask diversion—which almost always accompanies
diversion—can result in additional liability
exposure. The level of risk to the agency may
depend upon its controlled substance usage
policies and the degree to which these policies are followed, as well as the service’s system for handling narcotics. The cost of an
impaired employee can’t be overlooked. Use of
sick time results in paying others overtime to
cover shifts. There’s often decreased efficiency,
and a failure to act can result in diminished
morale within the service.
Another issue is whether your service
requires a “reasonable suspicion” or “probable
cause” standard to test an employee for sus-
pected impairment. Collective bargaining to
increase the level of suspicion needed may use
this standard as leverage.
Formulations that incorporate physical or
pharmacologic impediments to altering the
recommended routes of administration may
deter tampering, but there are advantages and
disadvantages to temper resistant formula-
tions. At present, only a few formulations of
oral opiate analgesics with characteristics
designed to oppose tampering for abuse have
received approval by the U.S. Food and Drug
Administration, and none has been permit-
ted to include claims of abuse deterrence or
tamper resistance in their labeling. 7
John Sinclair, fire chief for Kittitas Valley
(Wash.) Fire Rescue, detailed his agency’s
response to their first case. “After a 42-year
clean history, we experienced our first loss
of narcotics. We immediately conducted an
investigation with the police, with complete
transparency and changed our policy.”
Patients who haven’t received appropri-
ate medications as a result of drug tampering
may have cause to file civil lawsuits against the
EMS provider as well as the EMS agency for
claims such as battery and lack of informed
consent. If fentanyl is medically indicated for
a patient but the patient receives only normal
saline from a tampered vial, this could result in
a negligence claim against the service.
The service medical director may also face
civil liability in the form of licensure action
and fines. Again, this will depend upon the
level of involvement of the medical director
and whether swift action was taken when the
diversion was recognized.
Finally, and certainly not least, media coverage of drug diversion in EMS damages the
reputation of the service in the community
and breaches the public trust.
Sinclair notes that it’s imperative for an organization to put energy into prevention efforts,
including policies, supervision and swift action
when an issue arises. Check which drugs are
ordered by supervisors, and in what amounts.
If some providers tend to use more analgesics
than others, particularly for complaints of back
pain or abdominal pain, a chart review should
Be on alert for employees who perform
poorly, have a disheveled appearance and use
excessive sick leave. Employees with family
or financial problems are at considerable risk.
Supervisors should know what happens to
wasted and expired meds. Access to narcotic
pain medications should always require two
providers, as it’s not uncommon for the addict
to be the one person with uncontrolled access
to the narcotics.