Alcohol use disorder and other substance use disorders represent a significant problem for healthcare professionals. Without identification and appropriate treatment, impairment usually progresses and compromises not only the workplace but, more importantly, threatens patient safety. The danger is significantly worse when the impaired health professional is responsible for treating critically ill patients in the intensive care unit, emergency department, or operating room. Medical professionals must recognize signs of this disorder in their peers for the sake of patients and those afflicted healthcare providers themselves.
Health professional impairment is, unfortunately, much too frequently seen. Impairment results when a health professional, a physician, nurse, or allied health professional is unable to provide competent and safe patient care because of any substance use disorder. Any illicit substance, as well as prescription and non-prescription drugs, can impair the professional. Impairment may also result from a psychological or physical condition that affects the health professional's judgment, such as overwhelming chronic pain. Any disorder, mental, physical, or substance-related, can cause the healthcare professional to lose focus and be unable to safely and effectively perform the duties required by their profession. Recognition of this inability to safely and effectively perform to the best of their ability is the determining factor in recognition of any performance-limiting impairment.
All health professionals must be aware of the safety issues that become apparent when a health professional is impaired. Ultimately, the signs and symptoms of impairment and the state and institution requirements for reporting individuals suspected of working while in an impaired state are critical to preventing injury to patients and loss of the professional expertise of afflicted colleagues.
Impaired health professionals usually develop coping mechanisms that allow them to initially cover up their diminished capacity to provide safe patient care. Eventually, mistakes become more evident, medication errors are made more often, or procedural errors become more apparent. Initially, these violations may be subtle, and only an astute and observant fellow practitioner will notice a change in behavior or the signs and symptoms of impairment. One common occurrence is the diversion by a health care professional of controlled substances such as opioids and benzodiazepines from a patient to themselves. The diversion can result in a patient being under-medicated or suffering unnecessarily due to a lack of appropriate medications.
The misuse of substances over time also may result in the deterioration of the health professional's well-being. Use of stimulants, for example, may result in cardiovascular problems such as angina, hypertension, and myocardial infarction. Alcohol can lead to liver diseases such as cirrhosis. Patients suffer exposure to infectious diseases such as human immunodeficiency, hepatitis, and other blood-borne diseases. There are often coexisting mental disorders such as depression and anxiety; suicide can be an outcome for some. Impairment can lead to traumatic injuries such as falls, fractures, and head injuries.
Florida State and Federal Rules and Regulations
Virtually all states include rules and regulations regarding the use of alcohol and drugs as the basis for disciplinary actions. Authorities deal with the diversion of drugs from patients very harshly. Almost all states also require reporting of health practitioners suspected of impairment. These rules and penalties vary from state to state.
The Florida Nurse Practice Act is an example of the typical state law regarding the use of controlled substances and the necessary reporting.
464.018 Disciplinary Actions
(h) Unprofessional conduct, which shall include, but not be limited to, any departure from or the failure to conform to the minimal standards of acceptable and prevailing nursing practice, in which case actual injury need not be established.
Most states require reporting of unprofessional conduct, whether it be by a physician, nurse, or allied health professional.
(i) Engaging or attempting to engage in the possession, sale, or distribution of controlled substances as set forth in chapter 893 for any other than legitimate purposes authorized by this chapter.[leg.state.fl.us, 2018]
All states and the federal government take a dim view of healthcare practitioners who engage in the unlawful sale of prescription or nonprescription controlled substances. Penalties for violation can include fines and jail sentences.
(j) Being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, opioids, chemicals, or any other type of material or as a result of any mental or physical condition. In enforcing this paragraph, the department shall have, upon a finding of the secretary or the secretary's designee that probable cause exists to believe that the licensee is unable to practice nursing because of the reasons stated in this paragraph, the authority to issue an order to compel a licensee to submit to a mental or physical examination by physicians designated by the department. If the licensee refuses to comply with such an order, the department's order directing such examination may be enforced by filing a petition for enforcement in the circuit court where the licensee resides or does business. The licensee against whom the petition is filed shall not be named or identified by initials in any public court records or documents, and the proceedings shall be closed to the public. The department shall be entitled to the summary procedure provided in s. 51.011. A nurse affected by the provisions of this paragraph shall, at reasonable intervals, receive an opportunity to demonstrate that she or he can resume the competent practice of nursing with reasonable skill and safety to patients.
All states have varying rules regarding the evaluation and prosecution of a healthcare practitioner who, due to mental illness or illicit use of controlled substances, places a patient's safety at risk. Health professionals have been prosecuted for felonies for harming patients due to unprofessional and dangerous conduct.
(k) Failing to report to the department any person who the licensee knows is in violation of this chapter or of the rules of the department or the board; however, if the licensee verifies that such person is actively participating in a board-approved program for the treatment of a physical or mental condition, the licensee is required to report such person only to an impaired professionals consultant.
Most states require health professionals who they believe are impaired to report to the appropriate authority. Failure to report may have negative consequences for the health practitioner who is aware of the impairment and fails to report to the proper authority.
(l) Knowingly violating any provision of this chapter, a rule of the board or the department, or a lawful order of the board or department previously entered in a disciplinary proceeding or failing to comply with a lawfully issued subpoena of the department.
If the health professional knowingly violates the provisions, the consequence in most states is even more severe. All health professionals are obligated to be aware of the Practice Act rules and regulations in each state in which they hold a license.
(m) Failing to report to the department any licensee under chapter 458 or under chapter 459 who the nurse knows has violated the grounds for disciplinary action set out in the law under which that person is licensed and who provides health care services in a facility licensed under chapter 395, or a health maintenance organization certificated under part I of chapter 641, in which the nurse also provides services.
Most states have the right to specifically penalize a health professional who fails to report another health professional whom they know violates state laws. Besides the legal concerns, health professionals have an ethical and moral duty to patients to report a health professional with a diminished capacity to perform their duties.
(4) The board shall not reinstate the license of a nurse who has been found guilty by the board on three separate occasions of violations of this chapter relating to the use of drugs or opioids, which offenses involved the diversion of drugs or opioids from patients to personal use or sale.
In many states, the ongoing use of drugs or alcohol can result in the permanent loss of a medical license.
It is crucial that all health professionals review the Health Practice Act in each state where they hold a license and that they comply with the reporting requirements. If one is unsure of the requirements, most institutions will provide an attorney or other professional to understand the reporting process.
Most states have statutes to help healthcare practitioners identify and treat impaired healthcare providers. Virtually all state medical boards require that a healthcare provider suffering from alcohol or drug substance use self-report, and individuals aware of the problem must report their peers. Due to the fear of reprisal, most states have a mechanism whereby a provider can confidentially report a peer directly to an agency that can investigate and deal with the problem. Providing there are no safety issues that directly affect a patient's care, the impaired practitioner can engage in treatment and rehabilitation and avoid board disciplinary action.
If a health professional is already under discipline, has been terminated from rehabilitation, has sold drugs, or is at continuous risk to the public, the practitioner is less likely to receive the opportunity to seek private treatment without public consequences. However, if there is no danger to the patients, even The Joint Commission supports treatment rather than punishment.
To a certain extent, federal laws protect health professionals with substance use disorders. The Americans with Disabilities Act provides protection for healthcare providers in treatment and recovery programs for substance use disorders. It requires a "reasonable accommodation" for an individual who recognizes their alcohol or drug issues and participates in a rehabilitation program. Federal law does not consider a person to have a disability because they are using drugs. The Family Medical Leave Act requires employers to allow time off for qualified substance use disorder treatment.
Courts and statutes usually protect healthcare providers' and medical boards' efforts to address substance use disorder issues, particularly if practitioners have successfully completed treatment. However, if a practitioner harms a patient while under the influence of drugs or alcohol or an institution knowingly fails to protect a patient, the consequences can be severe. Examples include the following:
A court granted immunity to the director of an impaired practitioner program, who suggested that healthcare professionals' privileges be suspended until they completed substance use disorder evaluation and treatment.
During a medical malpractice case, a healthcare professional refused to turn over substance use disorder treatment records; the court ruled those records were privileged and confidential.
A court dismissed a hospital from a malpractice suit that claimed negligent credentialing due to a health professional's prior alcohol and drug use. The court found the professional had completed successful treatment and had complied with a monitoring program for years, and the hospital acted reasonably in granting privileges.
A patient sued the hospital for improper credentialing because the health practitioner had committed malpractice in the past and was known by the hospital to be addicted to sedatives. The hospital was assessed punitive damages for negligent credentialing.
A health professional admitted to being under the influence of an opiate during a surgical operation, and there was a large punitive verdict awarded.
Definitions
Addiction: A substantial loss of self-control indicated by compulsive alcohol or drug use despite the desire to stop. It may involve cycles of relapse and remission, and if untreated, may result in disability or premature death.
Drug diversion: The transfer of a controlled substance, such as a drug, from a lawful to an unlawful channel of distribution and use.
Substance use disorder: A disease of the brain characterized by the recurrent use of alcohol or drugs that result in functional impairment such as disability, health problems, and failure to meet responsibilities at home, work, or school.
Impairment: The inability or impending inability to provide safe, professional activities and duties due to a behavioral, mental, or physical disorder related to alcohol or drugs.
Consequences of Healthcare Professional Impairment
Patients
The decreased trust of health professionals
Infection from contaminated needles
Medical error victims
Reaction to wrong drugs
Undue pain
Peers
Discipline from failure to report
Legal liability from shared patients/shared patient care
Stress from increased workload as a result of an impaired professional
Professionals
Accidental injuries
Billing and insurance fraud
Communicable infections from the use of unsterile drugs and needles
Felony prosecution
Heart disease
Liver disease
Malpractice actions
Institutions
Civil liability from failure to recognize an impairment
Decreased institutional reputation
Decreased revenue from diverted drugs
Poor work quality
Increased absenteeism
The increased cost of Workers' Compensation
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