# A registered nurse discovers that a colleague has been diverting controlled substances from the medication dispensing system. The colleague approaches the nurse and asks not to report the incident, claiming personal problems and promising it won't happen again. What is the most appropriate action for the nurse to take?

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> subject: Critical Care

## 문제

A registered nurse discovers that a colleague has been diverting controlled substances from the medication dispensing system. The colleague approaches the nurse and asks not to report the incident, claiming personal problems and promising it won't happen again. What is the most appropriate action for the nurse to take?

## 보기

1. Agree to keep the incident confidential and monitor the colleague's behavior closely
2. Confront the colleague directly and demand immediate cessation of the behavior
3. Wait to see if the behavior continues before taking any action
4. Report the incident to the appropriate supervisor or authority immediately **✔ 정답**

**정답: 4**

## 해설

The nurse must report suspected drug diversion immediately to protect patient safety and comply with legal and ethical obligations. Other options violate professional standards by delaying action or failing to report.

## 심화 해설

Core Nursing Explanation
**Key Concept Analysis**: This question tests the nurse's ethical and legal duty to report a colleague's unsafe and illegal practice. The core issue is drug diversion, which is the unauthorized removal of prescription medications, typically controlled substances, from their intended use. This act threatens patient safety (patients may not receive needed medication), violates the law, and indicates a potential impairment in the colleague that could affect their professional judgment and care delivery. The nurse's primary responsibility is to the patient and public safety, not to protect a colleague from the consequences of their actions.

**Answer Rationale**: Key Point! The most appropriate action is to Report the incident to the appropriate supervisor or authority immediately. This is mandated by the American Nurses Association (ANA) Code of Ethics, state nurse practice acts, and federal law. Reporting is a non-negotiable professional obligation to protect patients and ensure a safe healthcare environment. It is not a matter of personal loyalty but of professional integrity and public trust.

**Distractor Analysis**:

Watch out for confusion! Option ① (Agree to keep it confidential) violates the nurse's ethical duty to report and constitutes a cover-up of illegal activity. It places the nurse in legal jeopardy and fails to protect patients.

Option ② (Confront the colleague directly) may seem assertive, but it is not the safest or most effective first step. A direct confrontation could escalate the situation, allow the colleague to hide evidence, or put the reporting nurse at risk. The proper channel is through the organizational chain of command or reporting system.

Option ③ (Wait and see) is a dangerous delay. Drug diversion is an immediate threat to patient safety and a crime. Waiting allows the behavior to continue, potentially harming more patients and allowing the colleague's impairment to worsen.

**Related Concepts**: This scenario involves the ethical principles of nonmaleficence (do no harm) and justice. It also touches on mandatory reporting obligations and the concept of a culture of safety in healthcare, where all team members are responsible for reporting errors and unsafe conditions without fear of retribution.

Concept Summary

| Concept | Description | Nursing Implication |
| --- | --- | --- |
| Drug Diversion | Illegal transfer of prescription drugs from lawful to unlawful channels. | Immediate threat to patient safety; must be reported. |
| Duty to Report | Legal and ethical obligation to report unsafe, illegal, or unethical practices. | Overrides personal relationships; follow facility policy and state board of nursing guidelines. |
| Whistleblower Protections | Laws that protect employees who report illegal or unsafe activities from retaliation. | Nurses should report concerns through proper channels and document facts objectively. |
| Impaired Nurse | A nurse whose practice is diminished due to substance use, mental health, or physical illness. | Reporting is the first step to getting the colleague help through a state's Alternative to Discipline Program. |

Side-by-Side Comparison!

| Action | Rationale | Why It's Correct or Incorrect |
| --- | --- | --- |
| Report Immediately | Upholds patient safety, legal duty, and professional ethics. | Key Point! CORRECT. The only action that fulfills all professional obligations. |
| Keep Confidential | Misplaced loyalty; enables harmful behavior. | INCORRECT. Violates the Code of Ethics and could lead to legal liability for the nurse. |
| Confront Directly | May address the person but bypasses the system designed to handle such issues. | INCORRECT. Not the safest or most procedurally sound first step. Reporting comes first. |
| Wait and See | Passive; allows ongoing risk to patients. | INCORRECT. Fails in the duty to act to prevent imminent harm. |

Anatomy, Physiology & Pharmacology Points
While this is primarily an ethics question, the underlying pharmacology is critical. Controlled substances (e.g., opioids like morphine, stimulants) have a high potential for abuse and dependence. Diversion often involves these drugs. Nurses must understand secure handling, accurate documentation, and waste procedures for these medications to prevent and detect diversion.

Memory Tips
**Mnemonic: S.A.F.E. Report**

**S**ee it? (Identify diversion)

**A**ct immediately (Don't wait)

**F**ollow the chain (Report to supervisor/authority)

**E**nsure patient safety (The ultimate goal)

Remember: Your license and your duty are to your **patients**, not your colleagues. Protecting a colleague who is diverting drugs is protecting someone who is stealing from and potentially harming patients.

High-Frequency NCLEX Topics
Ethics, legal responsibilities, and professional boundaries are High Yield topics on the NCLEX. Questions often present a dilemma where the "right" action (reporting) may feel personally difficult. The NCLEX consistently prioritizes patient safety and adherence to law/ethics over interpersonal comfort.

Watch Out for Question Variations!
* Variation 1: The colleague is diverting for a **family member's** pain. (Answer: Still report immediately. The reason for diversion does not change the obligation.)
* Variation 2: The nurse is **unsure** but suspects diversion based on missing pills. (Answer: Report the suspicion to the supervisor for investigation. You are reporting a concern, not making a final accusation.)
* Variation 3: The question asks for the **first** action after discovering diversion. (Answer: Secure any remaining evidence if safe to do so, then report immediately. The core action is still reporting.)

## 임상 시나리오

Nursing Clinical Practice Guide
**Clinical Scenario**: You are working the night shift on a medical-surgical unit. While reconciling the narcotic count at change of shift, you notice a significant discrepancy in the oxycodone supply. Your partner nurse from the previous shift, who is a friend, had several patients requiring that medication. Later, you overhear another aide mention that the same nurse seemed "out of it" near the end of the shift. The next day, your colleague pulls you aside, admits to taking a few pills for a back injury, begs you not to say anything, and promises to get help on their own.

**Nursing Intervention Strategy**:
1. **Assessment**: Objectively document the facts: the medication discrepancy, the time, the witness statement (without names if possible, just "was reported by staff"), and the direct admission from the colleague. Do not investigate on your own.
2. **Planning & Implementation**: Your plan is to report. Immediately go to your nurse manager, charge nurse, or supervisor in a private setting. Report exactly what you observed and heard, presenting the facts without emotional judgment. Follow your facility's specific policy for reporting impaired practice or drug diversion.
3. **Evaluation**: The evaluation is not your direct responsibility. The organization will investigate. Your role is to ensure the report was made and to continue providing safe care to your patients. You may be asked to provide a written statement.

**Patient Safety and Precautions**:
* Your primary precaution is to ensure no patients under that nurse's care are currently at risk. If the colleague is scheduled to work, your report may trigger their immediate relief from duty.
* Maintain confidentiality about the incident with other staff. Do not gossip. The investigation is confidential.
* Be prepared for emotional difficulty. Reporting a friend is hard, but patient harm from diverted medication or an impaired nurse is far worse.

Nursing Procedure & Medication Flow
To prevent diversion, always follow the "Witnessed Waste" procedure for controlled substances. If you must discard part of a dose, a second licensed nurse must observe you wasting the medication into the designated disposal system and both must sign the record. Count controlled substances with the oncoming and offgoing nurses at every shift change, and investigate any discrepancy immediately. Secure medication carts and storage areas when not in use.

A Word from Your Senior Nurse
"This is one of the toughest situations you can face. It feels like you're betraying a friend. But let me reframe it: you're not reporting a 'person'; you're reporting a **behavior** that is endangering lives. That nurse is sick and needs help—help they are unlikely to get without intervention. By reporting, you are not only protecting every patient on that unit, you are also starting the process that could save your colleague's career and life through a treatment program. Staying silent makes you complicit. Have the courage to do the hard, right thing. That's what being a professional nurse is all about."

## 핵심 개념

- **Drug Diversion** — The illegal transfer of legally prescribed controlled substances from the individual for whom they were prescribed to another person for illicit use.
- **ANA Code of Ethics** — The American Nurses Association's guide for carrying out nursing responsibilities in a manner consistent with quality in nursing care and the ethical obligations of the profession.
- **Mandatory Reporting** — A legal requirement for certain professionals to report suspected cases of abuse, neglect, or unsafe practice (like drug diversion) to the appropriate authorities.
- **Impaired Nurse** — A nurse whose ability to perform professional functions is diminished due to substance use disorder, mental illness, or physical illness.
- **Whistleblower Protection** — Laws that protect employees from retaliation when they report illegal or unethical activities conducted by their employer or colleagues.

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