Improving Quality through Consumer Involvement

advocacy_word_cloudAs a Registered Nurse of 25 years I have always been humbled by the trust that patients give to us as health care providers. In particular the countless times patients accepted my care without question. This is a great honor and I am hopeful that I have never violated their trust and lowered their quality of care.
Why do I share this with you? Recently, personal experiences with the health care system have led me to reflect more on the importance of patient and family involvement in care and the impact this has on the quality of care provided. My experience has also prompted me to advocate through my blog to remind health care providers that each and everyone of us need to take the time to assure that all communication is clear, concise, and that patients and families have every tool necessary to understand what is happening and what the next steps are. I also want to advocate by providing consumers who read my blog with tools that will assist health care providers to consistently provide high quality care and reduce the possibility of potential errors in that care.
When we are ill and in need of hospitalization or medical and nursing care the last thing we want to worry about is whether or not we are safe in the care of others, let alone be involved in asking questions and actively seeking opportunity to learn more about what is happening to us in that moment. Our focus is on getting well and letting others “fix us” if they can. When we are feeling better or we are not so overwhelmed with what is happening to us, we can then engage, in the questioning and learning process. I have learned that at this point it is often to late. When we are well enough, it is time to be discharged and we are experiencing a whirlwind of information that seems comprehensible in the moment, but when we are gone and left to review our instructions alone or with family members, clarity waivers, inconsistencies in information are found, and many questions arise. At this point our health care providers are no longer so easily accessible. We may call for clarification, but we are led to an answering machine, or a message is taken, and return calls may or may not come.
So, how do we as consumers of health care take an active approach in our own care, or on behalf of a family member? How do we as consumers play an active role in assuring that quality is not in question and that we receive the care we deserve? Here are some suggestions:
1. Always Speak UP! I have found that the majority of patients and families are reluctant to speak up when something does not feel right or seem right. I have asked individuals why it is this way. Responses I receive range from “I am not the health care provider and they know more than I do” to “I don’t want to cause any conflicts that will change my care”. These thoughts are not uncommon but I would like to think as a health care professional that they are not reality. Health Care Providers, although educated for their role, are human too and have probability of making mistakes. If your care does not make sense or you have a feeling or thought that something is not right, Speak Up! I for one would welcome the opportunity to make a correction in the care I am providing or to reassure you and provide education. I do know other health care professionals would welcome the same.
2. Share everything you can! There is a recent commercial that shows a young woman seeking care for a specific problem, yet when she is being assessed by the primary care provider she does not openly communicate her symptoms. At the end of the commercial the young woman gains the courage to admit she was not being truthful and shares everything with her provider. Both she and the provider then begin to address and alleviate her problems.
Downplaying our symptoms for one reason or another is not uncommon. I believe that this comes as a result of fear, lack of trust, or our parental influence. This can be dangerous and our health care providers cannot help us properly alleviate or address our health issue or concern. I am not suggesting that we run to our primary care provider for every little ache or pain, but when we do seek treatment it is important that we are honest about our symptoms and our medical history.
3. Question, Question, Question! When I am in a classroom teaching nursing students I will often encourage them to question like a three year old. I want them to ask Why? Why? Why? I want them to be active in their learning and to seek out every possible answer and explanation. The same is true for consumers of health care. Before you visit your primary care provider make a list of all of your questions and assure they are answered to your satisfaction. Do not worry about whether you will irritate your practitioner with your questions and do not settle for explanations you do not understand or leave you with more questions. Ask until you are satisfied and you know everything that is happening to you. If your primary care provider or your health care provider becomes irritated with your questions or does not respond to you, it may be time to consider transferring your care. Most care providers I know welcome these questions and find it helpful. This will leave you both satisfied with the care you are receiving.
If you are needing hospitalization the same is true. Make your list if you have time to do so. If you do not have this time due to emergency and you are alert to ask questions, ask them as they arise. I cannot possibly list every question to ask in this blog, but I can get you started, and lead you to a valuable resource for more. A few great questions to ask a hospital when you or a loved one require hospitalization are:
a. How many registered nurses do you have per patient?
b. How often will I see a health care professional?
c. Will I share a room or receive a private room?
d. What is your infection rate?
e. What time do physicians and primary care providers make rounds?
f. Do you have a patient advocate available should I need one? (Advocates are available in many hospitals when families cannot be present or a patient does not have family).
g. What is your patient fall rate?
h. What is your medication error rate?
I. Is a member of my family allowed to stay with me in my room during my hospital stay to serve as my advocate?
Also, do not settle for answers that do not provide you with clear understanding. For example, when receiving the results of your laboratory work answers like “it is in normal range” or “it is a little high” or “it is a little low” do not provide us with a clear understanding. It is okay to seek more detail. For example, what is the normal range?
The Agency for Health Care Research and Quality found at is also a great resource for questions consumers should ask to assist health care providers in the delivery of high quality low risk care. These questions include things like “what time is my test?”, “what type of preparation is required for my test?”, “what is this medication and what does it do?”, “what are the side effects?”, “what changes in my medication regimen are being made?” and more.
4. Keep an accurate medication list! This includes all prescribed, over the counter medications, and herbal or natural medications. Make sure this list is readily available when you need it. In today’s health care arena patients are visiting multiple providers as a result of specialization and even insurance provision. I have found through my own experiences that each provider may have a different list of what medications a patient is taking. I have also experienced transcription errors in the process of health care providers documenting medications. Having your list readily available for comparison and corrections will assist your providers in assuring the absence of potential medication errors.
5. Know your allergies and what type of reaction you experience! A great place to keep this information listed is on your medication list.
6. Make sure that when you leave a provider office or a hospital that you have an accurate and updated list of all medications and treatments. If you are being discharged from a hospital assure that the registered nurse provides you with the date and the time that the medications were last taken. Be clear on what was discontinued and what is continued or newly added. Medication errors after discharge are not uncommon and can cause significant harm. One 2014 health article found at identifies that “Overall, 20 to 30 percent of prescriptions are never filled, and 50 percent are not continued as prescribed, according to the U.S. Centers for Disease Control and Prevention.”
Once you have received the accurate and updated list, make your home corrections, dispose properly of your discontinued medications, and place the updated correct medication list where is easily accessible when you need it.
The health care environment can be overwhelming and frightening for many patients and families. Being armed with tools to assist you in the navigation of this environment and to provide you with control over the quality of care you are receiving can provide you with reassurance and decreased anxiety that is helpful in promoting a healthy outcome in the care you are receiving.
I am hopeful that you have enjoyed this weeks Talk Tuesday and have found at least one take-away or tool that can be of help to you today. If you are interested in learning more about me and the services I provide as a legal nurse consultant, trainer, and educator please take time to visit my website at If you would like to receive my blog updates please take time to leave your email on this page.
Talk Tuesday,

The Legal Nurse

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Legal Nurse Consultant (LNC), WHAT?


When I am met by others, even in my own Profession of Nursing and by some Attorney’s, I often receive a look of confusion when I respond to a question of “what do you do?” with the answer: “I am a Legal Nurse Consultant”. So I thought for today’s Talk Tuesday I would present the role of the Legal Nurse Consultant and hopefully convey to you an image of this role and how this role fits within the Legal Team as well as contributes to positive outcomes in Nursing and Health Care Delivery.

What is a Legal Nurse Consultant?

 A Legal Nurse Consultant (LNC) is a member of a specialty community of licensed Registered Nurses who critically evaluate and analyze facts and outcomes related to clinical and administrative nursing practice (Peterson and Kopishke, 2010). The LNC Serve’s attorneys, health care organizations and the greater community. The LNC is an expert in understanding and in application of the Professional Nursing Scopes and Standards of Practice.

As cited by the authors, there are 15 Standards within the Scope of Practice for the Legal Nurse Consultant (2010). Utilizing the nursing process as a solid foundation the LNC meets these approved standards through the many roles and responsibilities he or she has. These roles and responsibilities are integrated below in order of the cited Scopes of Practice (2010):

  • Understands the importance of and performs comprehensive Collection of pertinent data related to the case being assessed
  • Identifies issues related to the case assessed utilizing a critical analysis process and skill set
  • Uses both clinical and theoretical evidence based experience and knowledge to identify appropriate outcomes expected as a result of the plan or case
  • Identifies and collaborates with the legal team and/or health care organization on the development and strategizing of a plan to achieve outcomes
  • Uses his or her skills to implement the plan for achieving these outcomes
  • Maintains excellent organization and communication skills to coordinate services needed to achieve outcomes
  • Serves as a nurse educator to assist others (attorney’s, health care providers, administrators and more) in the understanding of standards of practice and the legal issues related to a case or claim
  • Serves as a collaborator for implementation of the plan, change management, and support for others. Collaborates with others in the conduct of Legal Nursing Practice
  • Serves as an evaluator for the achievement of outcomes
  • Is systematic in the assurance of quality and safety in nursing practice
  • Is knowledgeable, skilled, and educated in Legal Nurse Practice and maintains competency in nursing practice according to the American Nurses Association and American Academy of Legal Nurse Consultant Scopes and Standards for Practice. Also, maintains competency requirements of the State(s) and organizations in which he or she is licensed.
  • Constantly and consistently performs self-evaluation of his or her Professional Practice
  • Promotes the growth and development of other professionals and focuses on building positive working relationships
  • Is knowledgeable of the Code of Ethics for Nursing practice and demonstrates in his or her own practice how to practice according to the Code of Ethics
  • Has developed excellent research skills and ability to prudently integrate research into practice
  • Is a Leader on all levels of Professional Nursing Practice

 Where do Legal Nurse Consultants Work?

  • Independent Consulting Practice
  • Law Firms
  • Hospitals
  • Other Health Care Organizations
  • Insurance Companies
  • And more. . .

What types of Practice do Legal Nurse Consultants contribute to?

  • Fraud
  • Forensics
  • Personal Injury
  • Malpractice
  • Toxic Tort/Mass Cases
  • Administrative Law
  • Life Care Planning
  • Employment Law
  • Occupational Safety
  • Specialty Nursing Areas (for example: Obstetrics, Pediatrics, Surgery. . .)
  • Insurance (Medicare)
  • Nursing Homes
  • And more. . .

What Roles do Legal Nurse Consultants Serve In?

  • Consultants
  • Quality and Risk Management
  • Educators
  • Researchers
  • Facilitators
  • Advocate
  • Expert Testimony
  • Change Management
  • Project and Process Improvement
  • And more. . .

What a Legal Nurse Consultant is NOT:

Although Legal Nurse Consultants may be trained in the roles and responsibilities of a Paralegal, the Legal Nurse Consultant is not a Paralegal (2010). LNCs are a specialty of nurses who are licensed and hold a degree or degrees in Nursing in addition to their degrees and certifications as a LNC. This makes them a valuable member of any legal or health care team in that they can be relied upon to provide informed opinions regarding nursing and health care practice. It may not be unusual however for a LNC to provide assistance to attorneys in the area of paralegal support in certain situations (2010). Nurses are highly skilled in critical thinking and problem solving and understand the importance of remaining flexible in the care of others.

How do Legal Nurse Consultants Positively Impact Outcomes in Nursing and Health Care Delivery? Here are two of the most important areas of Impact.

Financial Impact:

LNCs are an economical choice for Attorney’s, Law Firms, and Health Care Organizations. Because the Legal Nurse is a trained and experienced Registered Nurse the skills needed to navigate medical records, identification of medical and nursing issues, navigation of organizational structures and environments, improving processes, providing knowledgeable expert opinion, and more, time is not wasted in the learning process or in overcoming barriers to achieving outcomes.

Advocacy Impact:

LNCs spend much of their time in evaluation and research of law, current practices and in the application of evidence in nursing practice. This is done in relation to the Scopes and Standards of Practice related to the Profession and Specialty area in question. Because of this responsibility LNCs are able to quickly identify areas of liability that exist in a case or in a health care organization. Not just skilled in the area of identification of these liabilities the LNC is skilled in providing recommendation and opinion based on evidence for the elimination of both actual and potential liabilities.

LNCs are also excellent educators and can be heavily relied upon by the legal team to clarify issues, bring vision to the case, and more. LNCs are also valuable to both health care and non-health care organizations seeking knowledge on Standards of Nursing Practice and on how to make their organizations a healthier place to work.

Are you looking for a Legal Nurse Consultant?

I would love for you to take some time in review of my website and services. You can find this site by clicking on this link Please do not hesitate to contact me. I would love to hear from you and discuss how I can assist you.

In addition to working with Attorney’s and Health Care Clients I provide workshops, presentations, conference sessions, and more. I also provide many topics of interest such as bullying, sexual harassment, behavioral standards, Leadership and Team Building, and more, for both Health Care and Non-Health Care Organizations.

Thank you for taking the time to read this week’s Talk Tuesday. I am excited to share the role of the Legal Nurse Consultant with you and I am hopeful you have at least one take away from this presentation. I would also love for you to follow my weekly blog. Before you leave this site please take the time to enter your email address and receive my weekly blog posting.

Talk Tuesday,

The Legal Nurse


Peterson, A., M., & Kopishke, L. (2010). Legal Nurse Consulting Principles. 3rd edition. American Association of Legal Nurse Consultants. Boca Raton, FL. CRC Press



We Are Gatekeepers! A Nurses Week Message

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I have been so blessed these past 25 years to work with amazing colleagues in our nursing profession who understand and demonstrate what it means to be a nurse. Nurses who understand that caring includes acts of courage, accepting positions of power, doing the right thing, and serving our persons of nursing as leaders to promote positive outcomes. To these nurses, I would like to say thank you for all I have learned from you and for the opportunity to serve beside you. I look forward to many more years of caring together!

In honor of all of the nurses out there that give of themselves every day to make a difference in the lives of others I would like to share a brief excerpt from my book “We Are Gatekeepers: A Self-Reflective Leadership Challenge for Nurses at All Levels”. Thank you for all you do and for the actions you take daily to ensure your patients are safe and for your contributions to this amazing profession!

Are you a Gatekeeper who is engaged politically in your organization? For your patients? For you profession?

Does the idea of being politically active scare you or overwhelm you?

Have you ever thought, politics do not belong in this profession?

As gatekeepers, we must engage politically. It is necessary for nurses to learn how to navigate a formal organization system effectively. Just like power, being political is neither good nor bad. It is just a necessary responsibility to ensure the progression of the nursing profession and for the benefit of those we serve.

Relationships are Key

Politics occurs at every level of nursing and the most effective gatekeeper in regards to maneuvering through a political arena is the one who focuses on building and maintaining positive relationships in the environment of care. . .

To do this, gatekeepers must be active in their work. They must be trustworthy and practice with integrity. A gatekeeper must build positive relationships to assure a level of influence that actively affects all care processes in a positive way. In building relationships, gatekeepers do not have to strive to make all people happy or ensure that they are liked by everyone. I mean that as gatekeepers you practice from a foundation of evidence that supports your practice. It means that you have gained respect as a gatekeeper for owning who you are, accepting responsibility, and practicing with accountability, courage, and power.

It is important to recognize, that generally, we cannot make others happy and we cannot make everyone like us. True happiness comes from within. If someone does not have it, it is not your fault. Blaming others for a lack of happiness weakens political power and causes people to practice from a place of powerlessness. Worrying about being liked verses respected distracts us form our purpose of serving others and will misguide us along the path to safe patient care. Being political means that others are persuaded to believe in your message. It is about getting things done for those we serve and for our own professional growth. . .

Gatekeepers are viewed by our communities as caring professionals. However, caring does not only mean communicating an image of a guardian angel, caring hands, or the lady with the lamp. Caring means gatekeepers use their voice and take charge and ownership of the professional responsibility to be active in the care of others. Through political action gatekeepers serve as advocates, change agents, and visionaries for high quality care. . .

Thank you Nurses for your grace and your courage. Thank you for practicing as political agents for the care of others and yourselves. I am proud to be one of you in this profession and on this journey! I hope you have an amazing week of celebration.

I hope you enjoyed this weeks Talk Tuesday. If you are interested in a copy of my book, public speaking availability, or legal nurse services please visit my website at

Talk Tuesday,

The Legal Nurse


Keeping our Patients Safe from Harm

Handwashing picture

Health care-associated infections occur when people get an infection while seeking medical treatment for another health issue According to the Center for Disease Control (CDC) “1 in 25 patients suffer from a Health care-associated Infection” The World Health Organization (WHO) recognizes this issue as a world issue providing links to factors such as socio-economic status, sanitation, age, and more

Both the CDC and WHO recognize several factors for the cause of Health care-associated infections. These include but are not limited to:

  • The use of Catheters (Urinary, IV, Central and more)
  • Over use of antibiotics
  • Facility cleanliness (dirty floors, equipment, supplies and more)
  • Surgery

According to the Patient Safety Network (PSNet) these infections cost the U. S. and the health care system “billions of dollars annually”  If you are curious as to the impact of Health care-associated infections in your organization specifically, the Association for Professionals in Infection Control and Epidemiology (APIC) provides tools such as a “cost calculator” in which you can enter your organizations specific data information. This tool can be found at:

The common theme in prevention of Health care-associated infections is hand washing. Hand washing is recognized as the number one prevention tool. Organizations such as the CDC, WHO, and APIC offer tools for training and education as well as surveillance of hand washing in your organization. The goal would be for every individual health care professional to take ownership and responsibility for the performance of hand hygiene consistently, prior to and after every patient encounter.

As a registered nurse and an assistant professor of nursing I not only teach about hand washing and its importance in infection prevention, but I have observed the inconsistency of it among health care professionals. Hand washing is such an easy thing to do, yet as noted above, the presentation by the CDC that “1 in 25 patients have an infection related to hospital care” is staggering. In 2014 the California Department of Public Health posted a presentation that includes barriers that prevent or deter health care professionals from performing this task consistently Although the importance of hand washing is receiving more attention these barriers still exist in 2018. Including barriers identified in this presentation, reasons for these barriers include but are not limited to:

  • Skin irritating agents leaving hands dry and cracked
  • Perceptions of the health care professional
  • Lack of knowledge about infection transmission
  • False sense of security with the use of gloves
  • Time for patient care
  • Lack of hand washing enforcement
  • Not enough sinks and hand sanitizing stations
  • Overuse of hand sanitizer and not enough hand washing with soap and water

How do we address this on-going problem? It is addressed through taking personal responsibility and ownership for the care we provide to patients and recognition that together we make up an organization. Therefore, when we say the organization needs to do more we are actually making a statement that we need to do more. The following is a list of some actions that can be taken to help patients remain safe from Health care-associated infections while in our care:

  • Follow the CDC guidelines at: Always use soap and water unless soap and water is not available. If soap and water is not available use an alcohol based hand sanitizer. Recognize that hand sanitizer does not wash away all germs.
  • Work together in your organization to create no-tolerance hand washing policies and enforce them
  • Engage patients letting them know that it is helpful for them to provide reminders for health care providers to wash their hands
  • Remind each other
  • Create a safe environment for reporting unsafe practice
  • Create a key words campaign to help the care provider remember to wash their hands. If the provider states “I am now washing my hands for your safety” both the care provider and the patient should expect that it will happen.

I am hopeful that you have enjoyed this “Talk Tuesday” informative discussion and have found at least one take away that you can apply in your practice today. Before leaving my site please take time to follow my blog and enter your email address. For Legal Nurse Services in medical record review, determination of merit, risk management, culture change, public speaking, and more please contact me via Talk Tuesday or visit my website at I would love to hear from you!

Talk Tuesday,

The Legal Nurse

Avoiding Legal Risk with Nursing Delegation

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Hypothetical Scenario’s

An RN delegates to a Licensed Practical Nurse (LPN) to initiate oxygen therapy that has been ordered by a physician on a patient with Chronic Obstructive Pulmonary Disease. The LPN accidentally sets the oxygen at a rate higher than what was ordered and the patient dies.

An RN prepares daily hypertensive medication for a resident in a nursing home, places it at the bedside and delegates to the Unlicensed Assistive Personnel (UAP) to assure the resident takes the medication with breakfast. The medication is forgotten and the resident suffers a stroke.

An RN directs a non-licensed Nurse Intern in his or her last year of nursing school to administer medications to a group of assigned patients in an acute care unit while he/she finishes documentation on each patient record. The nurse intern administers the wrong dose of a medication to one patient and the patient experiences a fatal reaction.


Delegation Responsibility

Delegation for an RN is a necessary skill to develop and to utilize in the care of patients. Without it an RN is not able to manage his or her workload and patient care suffers. If this skill is not performed prudently however, the above hypothetical scenario presentations, can become very real.

Delegation, according to the American Nurses Association (ANA), is “one of the most difficult responsibilities of the RN” ( Delegation requires that nurses are able to properly apply critical thinking skills and utilize high levels of clinical judgement to determine the appropriateness of the task or skill being delegated. This includes knowledge of the nurse practice act, scopes and standards for delegation in the state in which the nurse practices as well as knowledge of the scopes and standards of practice for the person being delegated to and the ability of that person to carry out the delegated task. The ANA also states that “RNs have authority, or legitimate power, to analyze assessments, plan nursing care, evaluate nursing care, and exercise nursing judgment (NCSBN) which includes delegation.” The RN maintains accountability and responsibility in the management of patient care, this includes the ability to delegate (


Delegation can be a scary experience for the new nurse who believes that if they delegate, the tasks will not be done correctly, and they have no control. Without it however, the new nurse will soon realize that the amount of care and responsibility they must manage due to staffing and financial difficulties in an organization is to overwhelming, and they must learn to delegate to assure each and every patient receives high quality care. For the experienced nurse, the risk may not be in the failure to delegate as it is with the new nurse, but rather the failure to assess, monitor, and evaluate the assigned delegated task. This occurs as a result of the demands of workload, as well as in my opinion, nursing fatigue and perceived lack of control over the environment in which the nurse is employed, while making every attempt to just get the volume of work done.  Of course, either the experienced nurse or the new nurse can make the mistake of not delegating when appropriate or failing to assess, monitor, and evaluate the assigned delegated task.

The key is for the RN to learn how to delegate properly and to gain confidence in their ability to delegate according to the standards for delegation. It is also important for them to follow the rights of delegation consistently, without missing a single step in the process, regardless of who they are delegating to.

Avoiding Risk

The National Council of State Boards of Nursing (NCSBN) in a joint statement with the ANA  list several principles for delegation that the RN must adhere to. If these principles, along with standards in the state the nurse is employed, are not followed the nurse places his or her professional practice at legal risk. These principles as stated in this joint statement include the five rights of delegation. These are:

  1. The right task
  2. Under the right circumstances
  3. To the right person
  4. With the right directions and communication; and
  5. Under the right supervision and evaluation.

All RNs are educated in their schools of nursing on the nursing process. The nursing process is an excellent tool to help guide the RN through the five rights above. Posted by the Missouri government this nursing process is used as a decision making tool for nurses to utilize and may be helpful for all nurses to review. A brief outline from this PDF is cited here:

  1. Assess your delegation criteria (these are stated in your states nurse practice act and scopes and standards of practice)
  2. Assess the situation
  3. Plan for the specific task to be delegated
  4. Assure appropriate accountability
  5. Supervise the performance of the task
  6. Evaluate the entire delegation process
  7. Re-evaluate and adjust the overall plan of care as needed


When performed correctly delegation is a very useful and responsible tool for the RN to utilize in his or her practice. This is not a skill that should be feared. The RN must be fully accountable and responsible in his or her nursing practice and this includes knowing when and how to delegate appropriately. When the rights of delegation are followed properly, risk in patient care is reduced, and optimal outcomes can be achieved.

Thank you for taking the time to read this week’s Talk Tuesday. I am hopeful that you are able to take at least one thing away to apply in your practice today. Please take time to enter your email address and follow Talk Tuesday. Also please take the time to click on this link to review my website and my services at

As a legal nurse consultant I not only provide medical record review and legal support for attorneys and medical clients but I also speak publicly on a variety of topics to improve the workplace and reduce risk.

Talk Tuesday,

The Legal Nurse

Grassroots Effort to Positively Impact Patient Care Outcomes by Addressing the Nursing Shortage

Medical doctor / nurse help wanted sign

It is recognized that nurses play an important role in the safety and quality of care. According to Clark and Donaldson, 2008 the Institute of Medicine (IOM) published a “landmark report” in 1996 recognizing this impact and focusing activities on improvements in healthcare quality These authors quote from this report, ““Nursing is a critical factor in determining the quality of care in hospitals and the nature of patient outcomes”1 (p. 92)” In 2018 primary focus for improvements on patient outcomes remains on nurse staffing and nurse satisfaction. According to the American Association of Colleges of Nursing (AACN) the U.S. is expected to experience an intensified nursing shortage as baby-boomers age The Bureau of Labor and Statistics (BLS) 2014-2024 report identifies that the “health care sector continues to outpace other employment when compared to other sectors”

This is great for employment opportunity for those seeking health care roles. The reality for nursing and for patient quality may not be so promising. Although nursing is listed as one of the “top occupations for job growth” the AACN cites the BLS noting that “the RN workforce is expected to grow from 2.7 million in 2014 to 3.2 million in 2024, an increase of 439,300 or 16%. The Bureau also projects the need for 649,100 replacement nurses in the workforce bringing the total number of job openings for nurses due to growth and replacements to 1.09 million by 2024” For those who are right to fill the role of the Registered Nurse this is great news. There is opportunity for employment. The reality is however that the roles and responsibilities of the Registered Nurse are challenging, ethically, morally, physically, and emotionally. It does not benefit the outcomes of our patients for nurses to serve in their roles because it is a job and there is always opportunity for employment. We need caring, compassionate, strong, independent yet collaborative, educated, patient focused nurses who have a passion for their work and who understand it is more than just a job.

There is more however, those that are right for the role of the Registered Nurse are seeking other opportunities because of these challenges. According to the Robert Wood Foundation (2014) “one in five new nurses leaves their first job within one year . . .”–acc.html. This is in addition to the large numbers of retiring nurses, the lack of nursing educators to be able to admit more students to nursing programs, and the lack of “young people” to replace retiring nurses Health Care environments are also to blame. Along with unfilled vacancies nurses are stressed with unsafe nurse to patient ratio’s, mandated overtime, fatigue, lack of growth opportunity, low pay, poor growth opportunity, minimal orientation opportunities, lack of mentorship, and hostile work environments.

In response to this on-going crisis our governing and leadership organizations such as but not limited to the American Nurses Association, Sigma Theta Tau International, and American Association of College of Nursing have taken action to promote awareness and campaign for the development of our profession. For example, as cited on the Sigma Theta Tau International website, Sigma Theta Tau International recognizes the on-going nurse vacancy issues as a “threat to the future of the world’s health care system” and they recommend steps to reverse this trend now

In addition to the on-going efforts of our professional leadership I believe that solutions to this crisis can also be found in grass-roots efforts to support positive patient outcomes. As nurses we need to rise up together and in continued effort to advocate for our patients to make changes at and from the closest to the patient level in care. Let’s take a look at just a few things we can do or do better:

Organizational Culture

According to Mackusick and Minik (2010) all nurses in their study reported an “unfriendly workplace” to be a cause of RN attrition or turnover The examples provided included sexual harassment, belittling, lack of support and nurses attacking their own. In 2011 the Health Foundation Inspiring Improvement published a report linking poor organizational culture and climate to patient care outcomes. Linkages between climate and outcomes found in this review of research, demonstrate increases in medication errors, readmission rates for congestive heart failure and heart attack patients, nursing injuries, urinary tract infections, decreases in patient satisfaction, and more. The article concluded that “hospitals with better safety climate overall had fewer patient safety incidents”

According to the University of Mexico, “the 2016 National Healthcare Retention and RN Staffing Report” identifies that “the average cost of turnover a nurse ranges from $37,700 to $58,400. Hospitals can lose $5.2 million to $8.1 million annually” and this cost continues to rise

Nurses, we must advocate for our patients. The financial loss that RN turnover causes to the organizations we serve is great and this trickles down to those we are here to serve. We need to stop our own negative and harmful behaviors toward each other. It is our responsibility to actively engage in the creation of a positive work environment and to demand that creating, maintaining, and sustaining a positive supportive culture be a priority. We have the right to also expect that our management and administration do the same and we must actively advocate for this to happen. Toxic managers and leaders should be provided with the opportunity to change or to move on. This is also true for toxic physicians, nurses, and staff.

Nursing Schools

In 2010 the National Advisory Council on Nurse Education and Practice published a report focusing on the Impact of the Nursing Faculty Shortage. In this report it is noted that applications to nursing programs are turned away do to the lack of faculty to teach in these programs. This discussion includes recruitment reasons such as low pay for educators, lack of supportive and creative learning environments and retention issues such as limited time to retirement once nurses have achieved the required qualifications to serve as nursing faculty

Sigma Theta Tau International recommends the promotion of higher education to nurses of all educational levels This requires creative and innovative opportunities to be designed by schools of nursing for nurses to return to school. Access to programs should not be limiting. High standards and rigor should be maintained however, this is necessary to avoid patient care errors, and turnover of professional nurses due to an inability to manage the stress and responsibilities of the role. As nurses a “grow your own focus” may just promote environments in which nurses do not eat their young but rather promote the growth and development of others, the profession and role model these positive behaviors.

I have personally talked with faculty who did not remain in their roles because they were expected to pass students who were unable to demonstrate safety, who were criticized for maintaining standards in the classroom, who were minimally paid and could not earn enough to pay back student loans for advanced degrees, or did not have support for creativity and growth in higher education. We need to assist those in higher education administration to understand the importance of safety in nursing care, building relationships and partnerships for our programs within and outside of the institution, and to provide support and resources to keep up with current teaching and practice standards.

Also, maintaining high standards is not the same as belittling and eating young. It is important for us to promote our standards and help others understand that the difficulty of school is not to be feared but rather welcomed to assure that all nurses are prepared to accept the roles and responsibilities for patient care. Nurses must be competent and knowledgeable and have the ability to function as a partner of the health care team. Rather than talking about how hard and awful nursing school is, we should be celebrating our success and be proud of the rigor and responsibility, sending positive images to those who are interested in becoming one of us.


Harrington and Heidkamp (2013) report that “by 2020 nearly half of all Registered Nurses will be traditional retirement age” How can we slow this inevitable situation? New nurses need the support and stability of our aging nurse population and patients need the level of critical thinking and action that this nursing population holds. In this same article strategies are suggested for retention of this valuable population of nurses. These include:

  • Ergonomics of the work environment such as lowering cupboards, moving work stations closer to the patient, better lighting in care areas, and resting locations for proper breaks
  • Creative scheduling that includes shorter work hours, flexible schedules, job sharing and mentorship and educator roles
  • Phased retirement strategies to create a gradual loss of experience giving time to the organization to train and prepare others to fill this void

When an organization and the nurses within that organization demonstrate a value for the experience and skill set of the nurses around them others do the same. It can be suggested that when employees feel valued, and that value is demonstrated, retention of all employees rise

Community and Political Involvement

Nurses, as a profession our leadership organizations such as the American Nurses Association, the National League for Nurses, Sigma Theta Tau International, and more, do much to promote us and to assure we have a political voice. These associations are focusing on the retention and growth of nursing as a profession. We all should be a member of a larger nursing organization and offer support where we can. We should be active in legislative efforts to increase standards in our profession, to assure we have safe staffing ratios and environments of care. When we are active we not only help to improve our own nursing experience but we help promote an image in which others want to be a part of.

There is also much we can do without needing to leave our back yard if we wish not too. It is important to communicate who we are and why our profession is important at our local level. To do this we can:

  • Run for local office
  • Join community committees
  • Participate in volunteer activities
  • Get involved in health policy development
  • Host community education opportunities
  • Engage in professional recruitment opportunities by allowing others to see and hear what you do

Being involved helps to promote our ability to advocate for our roles and our importance in the community. Nurses do not just exist in hospitals and demonstrating this provides others with an ability to see the diverse career opportunities nurse have. I believe nurses are the key to reducing health care costs in a community. Every community, business, organization, and school should employ them!

Thank you for taking the time to read this week’s Talk Tuesday. I am hopeful you have found at least one take away that you can reflect on and apply in your practice today. Before you leave my site please take time to follow my blog by entering your email address. I would also like for you to take the time to visit my website at

Talk Tuesday,

The Legal Nurse


Clarke, S. P., and Donaldson, N. E. (2008). Nurse staffing and patient care quality and safety. Patient Quality and Safety: An Evidence Based Handbook for Nurses. Retrieved at

Harrington, L. and Heidkamp, M. (2013). The aging workforce. Challenges for the healthcare industry workforce. The NTAR Leadership Center. Retrieved at

Mackusick, C. I. and Minik, P. (2010). Why are nurses leaving. Findings from an initial qualitative study on nursing attrition. Research for Practice. MEDSURG Nursing v19(6). Retrieved at

National Advisory Council on Nurse Education and Practice (2010). The impact of the nursing faculty shortage on nurse education and practice. Ninth Annual Report. Retrieved at

Research Scan (2011). Does improving safety culture improve patient outcomes? The Health Foundation Inspiring Improvement. Retrieved at

We Report! It is our Duty!


Imagine a scenario where a patient reports or you suspect that this patient has been harmed by another. This could be a situation in which a patient with dementia in a long term care setting harms another patient or a patient reports that they have been harmed by a staff member caring for them or by a family member. Maybe they were pinched, punched, grabbed, shoved, sexually abused, roughed up during care, or verbally assaulted. Maybe they have been financially abused by another.

Abuse is not always as obvious as the written words on paper. As nurses we often see the symptoms exhibited over a period of time. These symptoms include but are not limited to: (

  • Unexplained bruising and injury
  • Irrational fear
  • Depression
  • Acting out
  • Withdrawn behavior
  • Infection

Those in need of our care are in a vulnerable situation and they must rely on us as nurses to know our responsibilities, accept our responsibilities, and to act as an advocate for them. I discuss in my book “We are Gatekeepers: A Self-Reflective Leadership Challenge for Nurses at All Levels” that as Gatekeepers we must hold ourselves accountable, our behaviors, and our practice to do the right thing. “Simply, accountable behavior instills trust” (Covey, 2006). When a nurse is accountable and advocates for another, trust is built.

Accountability as noted in my book is not something that is imposed upon us. It is something we do for ourselves. It is something we accept. Others can only motivate us to be accountable, they cannot make us accountable. What does doing the right thing mean when it comes to understanding our responsibilities and our accountability in relation to the laws that govern abuse? It means that the law motivates us as nurses to accept our responsibility and accountability in our professional roles. It means that as nurses it is up to each and every one of us to understand our Federal and State laws, the standards that govern our practice and abide by them.

So what are our responsibilities in regard to assuring our patients are safe and free from abusive situations? The answer is to report suspected abuse! It does not matter if you have proof. The mere fact that you have assessed the potential and you are acting in good faith is reason enough. According to the U. S. Department of Justice “The federal government and states, the District of Columbia, and some territories all have statutes to protect older adults from physical abuse, neglect, financial exploitation, psychological abuse, sexual abuse, and abandonment” ( This is also true for child abuse as noted in “Duty to Report Suspected Child Abuse under 42 U.S.C sec. 13031” ( It is a necessity for you to also research your State’s Statutes for your mandatory reporting requirements and instruction on how and where to report.

As nurses it is our responsibility to become involved. Not acting out of a fear or a lack of desire to ruffle feathers is not an excuse for not reporting suspected abuse. Rationalizing our assessments and our suspicions is also not an excuse. Allowing ourselves to succumb to the request of a supervisor or administrator who suggests that we do not report is also not an excuse. As nurses, we do not judge. We report the facts and findings of our assessment. This is our responsibility as a professional nurse and a mandatory reporter. If you are in a situation where your responsibilities to report abuse are blocked, talk to a nurse attorney or an attorney about your concerns. If you would like education and assistance with policies and procedures to reduce your legal risk talk with a legal nurse consultant. As nurses we are all professionally responsible to uphold this duty.

I hope you enjoyed this week’s Talk Tuesday and you can find at least one take away to apply to your practice today. Please take time before you leave to enter your email and follow my blog. I would also love for you to visit my web-site In addition to working with attorney’s and medical professionals I speak on various topics including my book in venues both inside and outside of the legal and healthcare arena.

If you wish to purchase a copy of my book please visit

Talk Tuesday,

The Legal Nurse


Covey, S.M. & Merrill, R.R. (2006). The speed of trust: The one thing that changes everything. New York, NY: Free Press

Gerrie, J.L. (2016). We are gatekeepers: A self-reflective leadership challenge for nurses at all levels. Kingston Springs, TN: Westview

Back to Basics: Protecting yourself against Negligence and Malpractice in Nursing through Nursing Documentation

55f50_legal aspects of nursing

Most nurses have heard the phrase “if it is not documented, it is not done”. The reality is, this is not a true statement and a nurse may have very well provided care that was not documented. Not documenting the care we provide is careless and not living up to our responsibilities as an accountable nurse. On the other hand if it is done and not documented it can also be considered an omission, for example, an error in the care we provided. Not documenting properly according to our standards of care as nurses opens us up to liability for negligence and malpractice.

Negligence is defined according to Peterson & Kopishke (2010) as a failure to act as an ordinary prudent person would under similar circumstances (p. 7). Negligence requires proof of four elements. These are: “A duty”, a breach of that duty, “proximal cause” in which there is a connection between the breach of duty and the harm to the patient, and “damages or injuries” suffered (p.7). Professional negligence is not ordinary as the professional, such as the licensed nurse is held to standards of professional practice” (p.7). Standards of care determine or communicate the “reasonable conduct” and responsibility of the professional (p.7).

Malpractice according to Peterson & Kopishke (2010) is “misconduct, negligence, or failure to properly perform duties according to professional standards of care” (p.579).  According to the definition of Nursing Malpractice is “negligent or intentional actions by a nurse which causes injury or loss to a patient”

It is important to know and understand the laws and standards in the State in which we practice our nursing. In regard to documentation, failure to document in compliance with these standards can cause harm whether the failure to comply was intentional or not intentional. As a professional licensed nurse we have the duty and responsibility to perform documentation of the care we provide according to our communicated standards of care.

As an Assistant Professor of Nursing I teach students how to organize and document in the medical record. As a Legal Nurse Consultant one of my responsibilities is to understand how to organize records in a chronological order, interpret, and analyze the document data. I have come to understand that assuring that proper documentation standards are met in our practice settings can at times be challenging. Regardless of these challenges nurses must assure the following in their legal documentation (Taylor et. al. 2011):

  • Accuracy
  • Truthfulness
  • Timeliness
  • Objectiveness
  • Non-judgmental
  • Errors if handwritten are crossed out with one line, initialed, noted with the word error
  • Assure clarity and conciseness

Following the nursing process is also of great importance. The nursing process is our fundamental tool for problem-solving and decision making in our practice. Assure in nursing documentation and care to include and follow NANDA standards (Ackley & Ladwig, 2015) (Taylor et. al. 2011):

  • Assessment
  • Diagnosis
  • Planning
  • Implementation
  • Evaluation

Also, there are many other things to assure we document. These include but are not limited to (Taylor et. al 2011):

  • Any change in patient condition
  • Any provider notifications and orders
  • Any treatments the patient has undergone
  • Any medications administered
  • Refusal of any medications or treatments and care
  • Any interventions in care
  • Patient responses to the care provided and treatments performed
  • Any concerns or complaints voiced by the patient and/or family

There is also a list of what not to do in a legal medical record. All items on this list I have directly observed of others in my practice as a challenge for some. Keep in mind as you read through these, that as professionals we must never cover up errors in the medical record or alter the record in any way. This is not an all-inclusive list (Lockwood, 2017-2019,

  • Never use white out to make corrections
  • Do not abbreviate (even when using approved abbreviations clarity can be an issue)
  • Never chart in the future. If it is not done yet we cannot say it has been done.
  • Do not use subjective terms. Unless it is the patients exact words in quotation marks.
  • Never engage in work around’s when documentation systems are not working properly or when they are cumbersome or you are in a hurry
  • Never delete entries
  • Never alter documentation entered by another professional

I mentioned above that I have come to understand the challenges of completing this responsibility in our clinical care settings. Although the advancement of technology has presented us with potential for reduced risk and improved efficiencies it has not eliminated the risk of failure to document or failure to document appropriately. Only the nurse who documents can assure that his or her documentation meets the standard of care. If you are in an organization or a setting where documentation is difficult to complete according to the standards of care, as a professional nurse you hold the responsibility to advocate for an improved environment. Nursing management and the organization also have the responsibility to assure that documentation is able to be achieved according to professional nursing standards. Here is a non-inclusive list of actions that can be taken to assist in assuring your nursing environment is documentation safe:

  • Require and perform nursing documentation education
  • Perform routine medical record reviews to assess for documentation errors
  • Hold regular documentation quality meetings where these review findings are reported and discussed
  • Assure that your nurse to patient ratios and acuity are supportive of safe nursing practice
  • Know your standards for nursing practice and documentation and follow them
  • Assure your documentation tools are not only meeting regulation standards but are also designed for the needs of your patients, organization and nursing staff
  • Hire a third party such as a legal nurse consultant to assist you in examining your documentation practices, providing education, development of policies, and more.

Assuring proper documentation of all patient care should not be a burden in our nursing practice. This responsibility is of priority importance in the communication between the patient care team. Without excellent nursing documentation the care other professionals such as physicians, practitioners, therapists and more may not be appropriate for the needs of the patient involved ( As a key professional on the care team, the nurse’s documentation serves as the conduit for excellence in patient care and outcomes.

I hope you have enjoyed this week’s Talk Tuesday and have found at least one take away to apply in your practice today. Before you leave my site please take time to enter your email and follow my weekly blog.

I would also love for you to visit my website at As a legal nurse consultant I serve both attorneys and medical clients

Talk Tuesday,

The Legal Nurse


Ackley, B. J., Ladwig, G.B,, (2015). Nursing diagnosis handbook: An evidence-based guide to planning car. 11th ed. St. Louis, MO: Elsevier ISBN 978-0-323-39020-0

Lockwood, W. (2017-2019). Documentation: Accurate and Legal. Continuing Education. Retrieved at:

Peterson, A. M. & Kopishke, L. (2010) Legal Nurse Consulting Practices. 3rd ed. Boca Ranton, FL: CRC Press ISBN 978-1-4200-8948-6

Peterson, A. M. & Kopishke, L. (2010) Legal Nurse Consulting Principles. 3rd ed. Boca Ranton, FL: CRC Press ISBN 978-1-4200-8951-6

Taylor, C., Lillis, C. & Lynn, P. L. (2011). Fundamentals of Nursing: The art science of nursing care. 8th ed. Philadelphia, PA: Lippincott-Williams & Wilkins ISBN: 978-1-4511-8561-4

From Playground to Boardroom: What is the Cost of Bullying in your Organization?


Do you have a boss(s), colleague(s) or co-worker(s) in your organization that demonstrate behaviors that cause anxiety and fear in others? Do you find yourself or others making statements such as “that is just who they are” and the behaviors are allowed to go on? Have you ever had the feeling that you wanted to stay home from work because one or more individuals in your work environment cause you anxiety, or the environment has succumb to the behaviors and displays low-morale? I would bet we could all agree that bullying occurs on some level in almost all organizations. While as a society we focus mostly on bullying in schools and of school age children, bullying moves on from the playground to the boardroom. Bullying occurs in all levels of society and the workplace and it has become the “silent epidemic” in the workplace Let’s examine the cost of this behavior and some solutions for making your work environment safe.

The American Society for the Positive Care of Children (American SPCC) identify on their website at  that bullying can result in the following symptoms, but not limited to:

  • Headaches
  • Stomach aches
  • Depression
  • Anxiety
  • Reduced appetite
  • Aggression

The American SPCC goes on to discuss that:

  • “Children cannot get a quality education if they do not feel safe at school”
  • “160,000 children per day do not attend school for a fear of being bullied”
  • “The child who is overweight is the most likely to be bullied”

The long term effects of this behavior can be great including but not limited to, costing society life as a result of suicide or aggression toward others, and reduction in qualified work force as a result of not attending school or failing education.

When bullying moves from the playground to the boardroom many symptoms observed in school age children are recognized as early signs of bullying in the workplace. The Workplace Bullying Institute (WBI) notes on their website at that early signs of bullying include but are not limited to:

  • You are sick to your stomach the night before going to work or just before
  • You are irritable at home and your family complains that you obsess too much about work at home
  • You are calling in sick for “mental health days”
  • You do not enjoy your time off from work. You are exhausted and “lifeless”
  • You are experiencing physical symptoms such as high blood pressure, headaches, eating too much or too little, inability to concentrate and more. You may even be told by your physician to find another job.

Reflecting on these Identified symptoms by WBI organizations risk:

  • High rates of turnover
  • Low efficiency due to high absence rates
  • Financial instability due to an inability to serve customers and payment of sick time
  • A hostile work environment
  • Legal Action
  • Employees seeking to unionize

Let’s now take a good look at what bullying is and what it is not. First I would like to address what it is not. Bullying is not conflict with another person. Conflict as long it is respectful can be positive and can promote healthy change in an organization. Bullying is not disagreeing with another view point. Disagreement, when respectful can lead to healthy challenge of one’s thought processes and promote growth. Bullying is not supporting and acting on policies that prevent bullying or that motivate employees to be accountable for their actions and behaviors. As long as that action is respectful and supportive.

So what then, does bullying in the work place look like? The WBI defines bullying on their website at  At the risk of making this week’s blog a long read, I am cutting and pasting this information here for you. I cannot define it better and the WBI is a great resource for your further research on this topic. The WBI defines workplace bullying as:

“Workplace Bullying is repeated, health-harming mistreatment of one or more persons (the targets) by one or more perpetrators. It is abusive conduct that is :

  • Threatening, humiliating, or intimidating, or
  • Work interference — sabotage — which prevents work from getting done, or
  • Verbal abuse”

The WBI goes on to state that “Workplace Bullying. . .

  • Is driven by perpetrators’ need to control the targeted individual(s).
  • Is initiated by bullies who choose their targets, timing, location, and methods.
  • Is a set of acts of commission (doing things to others) or omission (withholding resources from others)
  • Requires consequences for the targeted individual
  • Escalates to involve others who side with the bully, either voluntarily or through coercion.
  • Undermines legitimate business interests when bullies’ personal agendas take precedence over work itself.
  • Is akin to domestic violence at work, where the abuser is on the payroll.”

The financial impact of bullying is also significant for organizations. Janet Fowler authored “Financial Impacts of Workplace Bullying” retrieved at: In this article she states that “somewhere between 20% and 50% of individuals have been subject to bullying in the work place”. Fowler, also notes the financial impact of this on the organization to include:

  • A possible 40% decline in productivity of employees focused on bullying
  • Research out of the United Kingdom that demonstrates lost work days to be as high as 18.9 million days which translates to a 10% profit loss
  • Up to 20% employee turnover rate for those employees who witness others being bullied
  • Up to 70% employee turnover rate for those employees who have experienced bullying directly

There are more costs to an organization identified and should raise concern for the financial health of the organization. These include legal actions taken for the failure to address bullying and to allow for the behaviors to continue. One legal website I found cited a case in which the victim was awarded $1, 360, 027 in damages for employer negligence in dealing with reported behavior and victimization

The above cited and stated risks to an organization are not all inclusive. The question however remains what can we do about it? If this behavior is an embedded behavior in society, how do we deal with it once it reaches the workplace? Here are some ways of managing this behavior, please note these are not all inclusive:


  • Self-reflect on your own behavior. Are you a dark leader?
  • Know the laws and how these laws impact your organizational environment and your responsibilities
  • Know the risk level of your organizational environment
  • Be consistent and fair and follow-up with all complaints of harassment, abuse, bullying
  • Be honest and do not minimize the behavior when it is reported
  • Assure anti-bullying policies and procedures are current and supportive of a no-tolerance environment
  • Educate on what bullying and harassment is and how to respond to it
  • Work with your staff to establish clear behavioral standards
  • Set clear expectations for all levels of employees from entry level to the boardroom
  • Provide opportunity for the bully to change, set expected courses of action, complete performance evaluations fairly and consistently
  • Provide for mental health benefits
  • If the bully cannot change let them go. Do not move them around the organization to affect others or demote them to other positions where they can still affect the work environment in a toxic way
  • Role model the appropriate workplace behaviors consistently


  • Self-reflect on your own behavior. Do you have a dark side?
  • Know the laws and how these laws impact your responsibilities
  • Be accountable for your own actions
  • Advocate for yourself and others by reporting bullying behavior
  • Work with your management and leadership to establish and maintain behavioral standards
  • Educate others on bullying behaviors when appropriate
  • Assist your management and leadership in the development of no-tolerance policies and procedures and follow them
  • Role model the appropriate workplace behaviors consistently



  • Be kind
  • Be respectful
  • Advocate for each other and step in and up when necessary
  • Set boundaries for how others may treat you
  • Understand what bullying and harassment is
  • Report when appropriate
  • Role model the appropriate workplace behaviors consistently


Thank you for reading this week’s Talk Tuesday. I am hopeful that you have found at least one take away that you can apply in your practice or organization today. Please take time to visit my website to learn more about me and my services at Also, before you leave my blog site please take the time to enter your email address and follow my weekly blog.

Talk Tuesday,

The Legal Nurse

Diversion Proof: Improving the Safety of your Health Care Practice and Organization


The Uniform Controlled Substances Act of 1994 Section 309 defines “diversion” as “the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use” ( In 2012 Physicians at the Mayo Clinic examined diversion in health care organizations and recognized that all health care organizations are not exempt from diversion activities, even themselves. In this publication, diversion is recognized as a “multi-victim crime” and discussion ensued about the necessity for health care organizations to develop systems that not only detect and prevent issues but to identify and respond to current ones (Berge, 2012). The United States Drug Enforcement Administration (DEA) communicate that “Diversion investigations involve, but are not limited to, physicians who sell prescriptions to drug dealers or abusers; pharmacists who falsify records and subsequently sell the drugs; employees who steal from inventory and falsify orders to cover illicit sales; prescription forgers; and individuals who commit armed robbery of pharmacies and drug distributors” (

Berg, et. al. 2012, also identified that anesthesia personnel, which includes both physicians and nurses, are at the greatest risk for diversion activity due to their direct access to necessary anesthetic medications. It is also noted by the Premier Safety Institute that outpatient settings are where most diversion activity occurs ( As noted above however, the DEA identifies that this risk involves many more health care professionals than anesthesia personnel and those in outpatient settings. In my opinion, it would be harmful to focus diversion proofing activities on only one or two health care professions or locations. Reality is that diversion proofing activities must address all professions within the health care system from Administration to bedside care providers and both inpatient and outpatient settings. Again, in my opinion, as health care providers we must assure that we do not contribute to the minimization of the problem by pointing fingers at each other, but rather solve the problem by considering all at risk, and strengthening our prevention strategies collaboratively in all areas of health care service.

At the end of this criminal activity it is the patient who suffers most. According to the Centers for Disease Control (CDC) this suffering includes but is not limited to denial of necessary treatment for pain, substandard care as a result of an impaired care provider, and increases in infection rates as a result of drug tampering ( Shafer & Perez, 2014 demonstrate the impact of diversion activity when they reported the results of their CDC records review, this is directly quoted,

“We identified 6 outbreaks over a 10-year period beginning in 2004; all occurred in hospital settings. Implicated health care professionals included 3 technicians and 3 nurses, one of whom was a nurse anesthetist. The mechanism by which infections were spread was tampering with injectable controlled substances. Two outbreaks involved tampering with opioids administered via patient-controlled analgesia pumps and resulted in gram-negative bacteremia in 34 patients. The remaining 4 outbreaks involved tampering with syringes or vials containing fentanyl; hepatitis C virus infection was transmitted to 84 patients. In each of these outbreaks, the implicated health care professional was infected with hepatitis C virus and served as the source; nearly 30,000 patients were potentially exposed to blood-borne pathogens and targeted for notification advising testing” (

Health Care is a patient first culture and we must be able to treat pain effectively for patients to experience healing and quality of life. However, to assure patients are receiving the care they deserve, and are at reduced risk for harm, we must become more aggressive in our approaches to dealing with this diversion issue. Recognizing that there is a statistically high rate of narcotic use in our country, according to Premier Safety Institute, “In 2015, 97.5 million people age 12 or older were past year users of opioid prescriptions” ( we have our work cut out for us. Most of this usage may have been for legitimate reason and a necessary care need and it may be impossible to eliminate all diversion activity. We can however, improve our systems and do all we can to prevent it, identify it, respond to it, and strive for a zero tolerance culture.

What strategies are there for the prevention of diversion activities? There are many, as diversion is not a one-sided issue. These activities include but are not limited to:

  1. Monitoring for and reporting insurance fraud
  2. Monitoring for and reporting prescription abuse
  3. Assuring safe medication administration processes
  4. Assure strict medication disposal processes
  5. Educate all staff and health care providers
  6. Assuring the laws are followed
  7. Developing and supporting a “safe” reporting culture
  8. Performing thorough chart reviews to identify missing and inaccurate medication documentation practices
  9. Establishing and following “no tolerance” policies
  10. Lobbying for stronger licensing penalties
  11. Promptly respond to and investigate any reported concerns, such as patients un-relieved pain or missing prescriptions
  12. Setting automated systems on the strictest dispensing settings to assure accurate dose dispensing
  13. Collaborate with other organizations, professions, and associations to learn how to balance the legitimate use and need with reduction of diversion risk

I hope you have enjoyed this week’s Talk Tuesday and can find at least one take away or resource that you can employ to contribute to the reduction of diversion risk in your organization or individual practice.

If you are interested in seeking my services as a legal nurse consultant in the areas of nursing assessment, diagnosis, planning, implementation or evaluation of your care environment and practices, I would love the opportunity to talk with you. If you are an attorney in need of medical chart review, or expert opinion, I am available to discuss your needs. To review my services and to contact me please visit

Before you leave please take time to enter your email address and follow my weekly blog.

Talk Tuesday,

The Legal Nurse


Berge, K.H., Dillon, K. R. , Sikkink, K. M., Taylor, T. K. , & Lanier, W.L. (2012). Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention. Retrieved at:

Centers for Disease Control at

Premier Safety Institute at

Shafer, M.K., Perez, J.R. (2014). Outbreaks of Infections Associated With DrugDiversion by US Health Care Personnel. Retrieved at:

The Uniform Controlled Substances Act of 1994 Section 309 at

The United States Drug Enforcement Administration at