Med diverter recently caught on my unit.

An RN who has worked in our ED for 15 years recently transitioned to ICU because she is about to finish her acute care NP and wanted the experience. She completed orientation a couple months ago and I have worked with her many times. I really liked her, she was fun and easy to get along with, also always willing to help. She seemed really intelligent and I was impressed with her de-escalation skills after I witnessed her calming down a patient who had been a pain in the ass for two days, and getting him to be cooperative and pleasant for the rest of the shift.

I did notice that she really liked to wander around the unit instead of staying with her patients. Our ICU is separated into “pods”, with 4 patient rooms and two nurses per pod. When you have a pod mate, it’s okay to walk away for short periods of time to get supplies, meds, and to take breaks. On several occasions when she had only one patient who was stepped down and awaiting an open floor bed, or once when she was a sitting with a patient and the primary RN was in the room, she would wander to my pod and to chat with me. She frequently would come into my patients rooms while I was in there providing care and offer to help me. Sometimes I’d take her up on her offer and ask for help with repositioning, but I’d usually first ask her if somebody was watching her patients and try to remind her that she cannot leave them unattended.

A couple days ago, I was shocked to hear that she had been caught in the act of pulling fentanyl right out of the IV bag of an intubated patent that was not assigned to her. It made me remember an instance a couple weeks ago when I was rushing to settle the patient I had just received at the beginning of my shift, because I was getting a direct admit from a different hospital who was in bad shape, and air med was en route. My fentanyl gtt, as well as me levophed was nearly dry, so I had grabbed new ones and was in the process of hanging them when my admit arrived. The new nurse from the ED was working in the pod next to mine and rushed over to offer assistance. She told me to go settle my new admit and she would hang my drips for me.

Later that night, my fentanyl tubing ran dry when the pump said there should have been 10ml left in the bag still. In that moment, I was annoyed and didn’t even think about how suspicious that was. It has recently occurred to me that my coworker probably stole some fentanyl while I was distracted with my crashing admit. It makes me wonder if her friendliness and helpfulness, as well as her tendency to wander away from her patients can all be explained by her drug diversion. I remember finding her tendency to leave her patients concerning, but she always told me they were being watched when I asked. I should have brought that concern to my unit manager as soon as I noticed it instead of trying to correct her behavior myself. There were subtle signs that something was not right from the beginning and I just mistook them for personality quirks.