The case of the disappearing CIIs


First installment of column on ethics


Eye on Ethics

The case of the disappearing CIIs

By Sue Bliss, R.Ph., MBA

Operating a pharmacy requires a blend of clinical skill, knowledge of pharmacy and business law, and ethics. When the law is ambiguous, good ethical reasoning can steer one toward a solid professional decision. This column will present situations common to every pharmacy setting and explore an ethical approach to problem solving. It is designed to help pharmacists protect patients and themselves, reducing the probability of legal action.

Q: CII medications are disappearing from the narcotics inventory in a large pharmacy. The pharmacists suspect a technician who has shown a pattern of erratic work performance. Suspicion in the workplace is eroding trust and is affecting the staff. What should the manager do?

A: When a pharmacy staff member is using or stealing drugs, the staff must be more vigilant than usual to make sure the person is not making drug errors. It is essential to conduct a speedy and discreet investigation to stop the loss of controlled substances.

First, reduce the opportunity to remove drugs from the pharmacy. If CIIs are sequestered in a narcotics cabinet, change the locks. Install security cameras and reevaluate supervisors' line of sight in the prescription-filling area. Check orders immediately against invoices, and note any discrepancies. Rotate this job periodically to prevent any employee from having sole responsibility for inventory.

Rotate work schedules also to prevent the same employees from working the same hours together, day after day. Install perpetual inventory software for easy tracking of controlled drugs.

Brief all staff members on your new security policies. Discourage speculation about the source of losses; the thief could be a pharmacist.

Observe the individual with the erratic performance carefully and compassionately. Are there extenuating circumstances at home? Is his or her workload unrealistic? Does he have any reason to resent coworkers or management? Are there physical or emotional patterns that suggest drug impairment? Do drugs disappear on days when he is not at work? It is critical that innocent employees are not wrongfully charged.

Decentralized automated dispensing systems in hospitals and emergency boxes in nursing homes are especially vulnerable to drug theft. All storage and dispensing systems should be tamper-evident, inspected by two sets of eyes, and signed out in a permanent record. When drugs disappear, losses should be pursued immediately. Employees inside or outside the pharmacy may be involved.

Although pharmacists are not routinely trained to distinguish drug abuse, they may become familiar with the physical and emotional signs of drug seekers' cravings for opioids, benzodiazepines, and other drugs. Drug abusers often target pharmacies right before closing, or when the pharmacy is extremely busy, in an effort to escape the pharmacists' full attention.

Pharmacy employees who abuse medication often look for opportunities when the pharmacy is understaffed. Drug abuse may begin by the removal of a few tablets from large, uncounted bottles of "fast movers" such as hydrocodone/APAP and codeine/APAP, kept within arm's reach on the production counter. Extra bottles of fast movers should be kept in a locked cabinet.

Once the culprit is identified, consult the institution's legal and human resource departments to follow the appropriate resolution plan. When an employee breaks trust with the employer, the consequences must be immediate. "PRN" programs in most states allow pharmacists and techs who abuse drugs or alcohol to enter treatment, retain their professional licenses, and eventually resume practice, if all program stipulations are met.

Some R.Ph.s diagnose and treat themselves, taking drugs from the prescription shelves. Casually taking even NSAIDs or antibiotics sets a very bad example for the staff and may subtly encourage drug theft.

It may take years to see positive results of an intervention. Intervention may prevent financial disaster for the individual and his family, or harm to patients. The offending employee may get help to cope with contributing stressors, or pursue a career change.

Pharmacists are scientific, concrete thinkers who fall back on their skills when facing a problem. An employee who abuses drugs or alcohol may exhibit behavior that defies logic. Uncovering and treating such problems requires intuition, logic, restraint, and great patience.

Disclaimer: This column highlights ethical situations that often occur in pharmacy practice. It is designed to stimulate discussion on how to deal with these situations and is not intended as legal advice. Pharmacists who need immediate assistance should consult their attorneys, employers, state boards of pharmacy, and state and federal laws.

The author has practiced long-term care and community pharmacy in Oregon for more than a decade, and has served on numerous professional and community boards.


Sue Bliss. The case of the disappearing CIIs.

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