Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014

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Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014
Robert J. Walters, Senior Assistant Attorney General
        Wyoming Attorney General’s Office
                    June 5, 2014
Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014
Introduction

:
Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014
Introduction

The prescription drug abuser, or drug seeker, represents a
serious and constant problem for the health care
professional in the United States.
These people, through a variety of methods, are successful
in obtaining an enormous amount of pharmaceutical drugs
from health care professionals. These drugs then
perpetuate personal addictions, or provide a very valuable
product to the prescription drug trafficker.

               :
Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014
Introduction

the health care professional is a
             nurse?
Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014
Introduction

                  THE FACTS
• Reliable statistics on the prevalence of drug diversion
  by nurses ARE NOT available
• By its nature, drug diversion is a clandestine activity
• Methods in place in many hospitals, facilities and
  institutions leave cases undiscovered or unreported
• Drug diversion by health care providers, including
  nurses, is universal among hospitals, facilities and
  institutions in the United States
Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014
Introduction

 Drug diversion may actually be under-reported.

• Fear of negative publicity
• Fear of State and Federal agency involvement
• Uncertainty about reporting requirements and avenues
• Justification that terminating the employee is enough
• Possible inadequate investigative systems in place
     :   Presentation: “Health Facility Drug Diversion: Essential
         Compliance & Auditing Measures,” by Kimberly S. New JD
         BSN RN, and Kelly C. Loya CPC-I, CHC, CPhT, CRMA
Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014
Introduction

          Consequences When
Diverter is dismissed/employment terminated or
allowed to quit:
•     May disregard the well being of the diverter
•     Opportunity for rehabilitation may be precluded
•     Potential violation of laws and regulations
•     No reported history will bypass preventive
screening at next employer
      :   Presentation: “Health Facility Drug Diversion: Essential
          Compliance & Auditing Measures,” by Kimberly S. New JD
          BSN RN, and Kelly C. Loya CPC-I, CHC, CPhT, CRMA
Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014
Introduction

Are drug diversion cases complicated?
Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014
Introduction

Can drug diversion cases look more like
medication error and/or documentation
     substandard practice cases?
Robert J. Walters, Senior Assistant Attorney General Wyoming Attorney General's Office June 5, 2014
Introduction
Introduction

Is it easy to PROCRASTINATE in
       drug diversion cases?
Introduction

  Is it ever too early to develop a
STRATEGY in drug diversion cases?
DUE PROCESS 101

BASIC RULE:
   NOTICE AND
OPPORTUNITY TO BE
     HEARD
Due Process 101

indicating the charges or GROUNDS FOR DISCIPLINE
upon which proposed disciplinary action will be based

    The Wyoming Administrative Procedure Act describes the notice
    requirement as follows:
    No revocation, suspension, annulment or withdrawal of any license
    is lawful unless, prior to the institution of agency proceedings, the
    agency gave notice by mail to the licensee of facts or conduct
    which warrant the intended action, and the licensee was given an
    opportunity to show compliance with all lawful requirements for the
    retention of the license.
    Wyo. Stat. Ann. § 16-3-113(c).
Due Process 101

       CONTESTED
       CASE
       HEARING
Due Process 101

  Music to a drug diverter’s ears
They think they are covered or that you can’t prove he/she diverted
Due Process 101

Accused nurse
has the legal
right for
opportunity to
dispute the
charges of
diversion
Due Process 101

        Usually not
        going to catch
        nurse with his/
        her “hand in the
        cookie jar”
Due Process 101

      Nurses oftentimes
      will deny diversion
      or any role in any
      suspected drug
      diversion
Due Process 101

      “I think you’d be
      surprised the
      lengths a drug
      addict will go to
      keep it a secret.”
      Nurse Jackie,
      “Lost Girls,”
      Season 5 (2013).
Due Process 101

Going to need
strong or solid
EVIDENCE of
   diversion
DUE PROCESS 101 --
   EVIDENCE

BURDEN OF PROOF
Due Process 101 -- Evidence
Due Process 101 -- Evidence
Due Process 101 -- Evidence

  or what are the ELEMENTS that must be proven?

   FRAMES NOT ONLY WHAT EVIDENCE MUST BE
PRESENTED AT A HEARING BUT WHAT EVIDENCE ALSO
      MUST BE OBTAINED IN INVESTIGATION!
Due Process 101 -- Evidence

             “Drug Diversion” Defined
   Diverting (or taking/removal of) a prescription
     drug for other than its intended purpose.
  Theft of medication, including “waste,” from patients or
           health care facilities for personal use.
Wyo. Stat. Ann. § 33-21-146(a)(v): “Has engaged in any unauthorized
possession or unauthorized use of a controlled substance as defined in the
Wyoming Controlled Substances Act[.]”
Due Process 101 -- Evidence

     “Misappropriation” Defined
  Negligently or deliberately taking, misusing,
 exploiting, using or selling property belonging
to another, whether temporarily or permanently,
         and without regard to consent.
Due Process 101 -- Evidence

             Emergency/Summary Suspension vs.
                   Hearing on the Merits
— Elements of the underlying         — Elements of the underlying
   ground(s) (e.g., drug diversion,      ground(s) (e.g., drug diversion,
   misappropriation, theft)              misappropriation, theft)
— Substantial likelihood of          — Clear and convincing evidence
   prevailing at hearing on              standard
   merits                             — Sanction imposed by Board is
— Nurse presents a clear and            not arbitrary or capricious
   immediate danger to public            (i.e., reasonable under
   health and safety if permitted        circumstances considering
   to practice.                          mitigating and aggravating factors)
Case Digest

Tale of Two Cases
Case Digest
Administrative complaint alleged:
ØAccording to Pyxis reports, nurse (LPN) removed twenty-six (26)
Fentanyl patches over the course of three (3) months that were
unaccounted for or not signed out on a resident Medication
Administration Report (“MAR”).
ØFentanyl patches were pulled day after day or on days that they were
not due to be changed.
ØThree (3) instances where nurse refilled the Pyxis machine with
Fentanyl patches and only refilled nine (9), which left one patch
unaccounted for each time refills occurred.
ØGreater administration of Percocet and Vicodin when nurse was
working, indicating a pattern in which five (5) residents were receiving
multiple doses of PRN narcotics and in which corresponding
documentation of administration was not reflected on the MAR or the
pain tracking sheet.
Case Digest
Initial recommendation by Disciplinary Committee:
ØReprimand for unsafe practice – i.e., medication errors, lack of
appropriate documentation (even though suspicious for drug diversion)
ØRemedial training in medication errors and documentation

Nurse was sent a proposed settlement agreement
(consent decree) for reprimand and training, which she
“happily” executed.

Board DID NOT approve proposed settlement
agreement (consent decree) for reprimand and training,
and suggested some level of supervision (worksite
monitor for an appropriate period with reporting).
Case Digest
Nurse retained counsel who communicated dispute of
alternative recommendation and requested a hearing.
In preparation for hearing, became more evident that
drug diversion ACTUALLY could be proven.
Case Digest
FACILITY’S INTERNAL AUDIT (data of three-month
period from Pyxis reports and corresponding medical
records) reflected:
ØNUMEROUS incidents of single nurse REMOVAL of
significant quantities Vicodin, Norco, Percocet, and
Fentanyl, related to several patients, and
ØVAST MAJORITY (approximately 85%) in which
ADMINISTRATION NOT DOCUMENTED, and
ØNO JUSTIFICATION for removal and lack of
appropriate care (assessment/reassessment) and failure
to document.
Case Digest
 ALTOGETHER, OVER 3-MONTH AUDIT PERIOD, NURSE
  REMOVED 236 UNITS OF NARCOTICS IN WHICH THE
  MAR REFLECTED ONLY 30 WERE ADMINISTERED!!!
   OVER 200 UNITS REMAINED UNACCOUNTED FOR.
    BREAKDOWN: Vicodin – 118 tablets removed/12 administered;
   Norco – 74 tablets removed/8 administered; Percocet – 21 tablets
removed/1 administered; Fentanyl – 32 patches removed/9 administered.

RE Patient “L.D.,”, nurse removed:
•80 Vicodin tablets, via 40 separate occurrences, of which
only 10 were documented as administered per the MAR.
•10 Fentanyl patches, none of which were documented
as administered per the MAR.
Case Digest
RE Patient “D.L.,”, nurse :
•Removed 21 Fentanyl patches, and ONLY 9 were
documented as administered per the MAR.
•Removed 8 Percocet tablets and ONLY 4 were
documented as administered per the MAR.
•Refilled/Inventoried 9 Fentanyl patches (one missing)
RE Patient “W.R.,”, nurse :
•Removed 19 Vicodin tablets and ONLY 2 were
documented as administered per the MAR.
•Removed 8 Norco tablets and ONLY 2 were documented
as administered per the MAR.
Case Digest
RE Patient “T.R.,”, nurse :
•Removed 9 Vicodin tablets and none of which were
documented as administered per the MAR.
•MAR reflected that Vicodin was not a prescribed
medication for this patient.
•Removed 12 Norco tablets and ONLY 1 was documented
as administered per the MAR.
•Removed 8 Ambien tablets and none of which were
documented as administered per the MAR.
•MAR reflected that Ambien was not a prescribed
medication for this patient.
Case Digest
RE Patient “D.S.,”, nurse :
•Removed 54 Norco tablets and ONLY 5 were
documented as administered per the MAR.
RE Patient “A.K.,”, nurse :
•Removed 1 Fentanyl patch, which was not documented
as administered per the MAR.
•This patient no longer at facility when patch removed.
RE Patient “C.T.,”, nurse :
•Removed 4 Percocet tablets, none of which were
documented as administered per the MAR.
•This patient was not assigned to nurse.
Case Digest
RE Patient “R.K.,”, nurse :
•Refilled/Inventoried 9 Fentanyl patches (one missing)
RE Patient “D.C.,”, nurse :
•Refilled/Inventoried 9 Fentanyl patches (one missing)
Case Digest
As part of disclosure requirements, and about two
weeks prior to hearing, communicated with nurse’s
attorney regarding evidence to be presented and
strength of case. Suggested that nurse consider a
voluntary surrender in lieu of hearing.
Nurse agreed to voluntary surrender and Board
approved a settlement agreement (consent decree) for
voluntary surrender.
WHAT was diverted?
WHAT do we know (or need to know)
about the diverter?
WHAT are the potential explanations
(or defenses) to accusations?
WHAT systems were in place (are there
issues regarding reliability)?
HOW was the situation discovered?
HOW did the suspected diversion occur?
HOW often were substances diverted –
i.e., was there a pattern?
HOW were patients impacted?
HOW extensive was investigation by
hospital, facility or institution?

HOW many other nurses or persons were
considered or investigated?
WAS suspected employee interviewed to
explain discrepancy (and what was
explanation)?
WAS suspected employee drug tested?
WAS suspected employee suspended or
terminated?
Most Commonly Diverted
                          Controlled Substances
                     vHydrocodone
                     vOxycodone
                     vHydromorphone
                     vMorphine Sulfate
                     vFentanyl
What was diverted?   vAlprazolam
                     vDiazepam
of a “Drug Diverter”

                      • High achiever or Model Nurse
                      • “Team Player”
                      • The last person you would suspect
What do we know
about the diverter?
of a “Drug Diverter”
                        •Medication removed on the controlled
                        substances sign-out sheets but not transferred
                        to or charted as administered on patients’
                        medical records
                        •Charts more controlled substances than other
                        nurses
 What do we know        •Noticeable increase of PRN or “as needed”
about the diverter?     controlled substances charted
 (Possible red flags)   •Charts out larger doses of controlled
                        substances than ordered when the appropriate
                        dose is available
of a “Drug Diverter”
                        •Excessive amounts of time spent near a drug
                        supply, such as a cart or medicine room
                        •Waits for other staff to leave controlled
                        substances unit before accessing medications
                        •Frequently checks supply of controlled
                        substances
 What do we know        •Preoccupied with medications
                        •“Disappears” at work (e.g., takes break or visits
about the diverter?     restroom especially after accessing controlled
 (Possible red flags)
                        substances)
of a “Drug Diverter”
                        •“Forgetfulness” in routine duties, including
                        decline in documentation
                        •Record keeping is sloppy -- some records
                        falsification is possible with drug shortages
                        •Changes evident in handwriting and charting
 What do we know        •Frequent overrides in automated dispensing
                        systems (ADS)
about the diverter?     •Frequently accessing the ADS after coworker
 (Possible red flags)   fails to log off the system
                        •Heavy “wastage” of drugs
of a “Drug Diverter”
                        •Makes unusual comments about usage/
                        disposal of controlled substances
                        •Defensive responses when questioned about
                        errors or poor patient care
                        •Asks coworkers for their user lD and password
 What do we know        •Asks coworker to sign for opioid wastage
                        without actually witnessing it
about the diverter?     •Asks for help accessing controlled substances
 (Possible red flags)   •Seen accessing ADS while off duty
of a “Drug Diverter”
                        •Night shift
                        •Critical care or other unit where nursing staff
                        have increased autonomy
                        •Volunteers for overtime, weekend or extra shifts
                        •Willingly “floats” to other units
 What do we know        •Works on a job lower than his/her educational
                        level
about the diverter?
 (Possible red flags)
of a “Drug Diverter”
                        •Patients and staff make complaints about the
                        co-worker’s attitude or behavior
                        •Significant stress in personal life
                        •Frequent hospitalization or accidents
                        •Personal history of being on pain medications
 What do we know        •Legitimate prescription for drug being diverted
                        •Wears long sleeves in appropriately, such as in
about the diverter?     very hot weather
 (Possible red flags)   •Slight hand tremors
                        •Pupillary size change and/or bloodshot eyes
What are the potential
explanations/defenses)
to accusations?
10. Prejudice or bias by management or other
                             coworkers
                         9. The Pyxis machine or ADS malfunctioned
                         8. Someone else had access to the Pyxis
                            machine and used my access information
                         7. Mistakenly administered to another patient
                            and did not (or forgot to) document/chart
What are the potential
                         6. Administered the medication but did not/
explanations/defenses)      forgot to chart
to accusations?
5. Chart portions missing or altered by
                            someone else
                         4. Someone else did it
                         3. Occurrence report filed but disappeared
                         2. I have no motive because I already
                            receive prescribed medication for pain

What are the potential
explanations/defenses)
to accusations?             I JUST DIDN’T DO IT!
Methods of Diversion
                        Removal from secure storage areas without
                        any documentation
                        Removal from storage area and falsification of
                        an order for administration
                        Removal and substitution in administration or
                        wasting
How did the suspected    • Substitution of look-alike pills
diversion occur?         • Saline substituted for injectable medication
                         • Potential for tampering
Methods of Diversion
                        Removal of medication without order
                        •Medication override
                        •Falsification of “verbal order”
                        Removal of medication when not needed
                        •Often initial method of diversion
                        •Very difficult to detect
How did the suspected   •Falsification of records
diversion occur?        •Medication errors
                        •No documentation of administration
Methods of Diversion
                        Removal for discharged patient
                        Removal of duplicate dose
                         • May not be assigned to care for patient
                        Removal under sign-on of colleague
                         • Stolen password
How did the suspected    • Left alone when colleague is signed in
diversion occur?        Removal and use from inconspicuous vessel
Methods of Diversion
                        Removal of/diversion from fentanyl patches
                         • Removal of gel with syringe and needle
                         • Keeping new patch for self and putting used
                           patch on patient
                        Removal from PCA and drip lines
                        Removal of unspent syringes from sharps
How did the suspected   containers
diversion occur?          • Nurse steals sharps containers and removes
                            syringes to collect remnants of syringes
Methods of Diversion
                        Failure to waste (properly)
                          • Claims he/she was too busy or others
                            unavailable to have a wasted dose witnessed
                          • Unwasted medication kept for self
                          • Waste thrown into the general trash and later
                            picked up by the diverter

How did the suspected   Frequent wasting of entire doses (should be
                        returned)
diversion occur?
                        Falsification of wastage record (to show a drug
                        was wasted, but may have wasted water)
Methods of Diversion
                        Charting of administration but patient was not
                        given quantity documented
                        Pilfering patient medications brought from
                        home
                        Nurse places drugs in coat, purse or car

How did the suspected
diversion occur?
Patient indications that drugs have
                    been diverted
                    • Patient who had been well controlled with pain
                      medication has marked change and increasingly
                      states pain is poorly controlled or exhibits signs
                      of increased pain.
                    • Response to pain medication varies with
How were patients     different caregivers.
impacted?           • Request for prescription refills are made with
                      increasing frequency.
Patient indications that drugs have
                    been diverted
                    • Appearance of drugs (pills, capsules) has
                      changed (indicating they may have been
                      replaced with non-opioid drugs).
                    • Patient may show signs of neglect (poor
                      hygiene, pressure sores, weight loss).
How were patients   • Patient may exhibit fear or anxiety, especially
impacted?             in the presence of a suspect caregiver.
Preparation of Drug
  Diversion Cases
Preparation of Drug
  Diversion Cases
Preparation of Drug
  Diversion Cases
         Can a PATTERN of drug
         diversion by subject nurse
         be demonstrated?
         vIs supporting evidence sufficient?
         vWhat are possible explanations or
         counter-indications?
         vIs the nurse’s “side of the story
         credible” – can it be rebutted?
         vIs there a smoking gun?
Preparation of Drug
   Diversion Cases

How
strong
is your
Preparation of Drug
  Diversion Cases
Preparation for Drug Diversion Cases

                          Evidence Needed
                             (MINIMUM)
•      Automated system audit (e.g., Pyxis report of removal of
substances by suspected employee over meaningful period of time)
•        Corresponding patient medical records (reflecting orders, charting
of pain assessments, medication administration, etc.)
•        Medication Administration Record (MARS) or Daily Medication Log
(DML)
•        Chart audits comparing physician’s orders, MARS or DML,
nurse’s notes & Pyxis reports (to determine if there is a discrepancy from
audits to show drug diversion – especially if there is a clear pattern)
Preparation for Drug Diversion Cases

                OTHER IMPORTANT EVIDENCE
 •       Copy of hospital’s or facility’s internal investigation
 documents
 • Patient complaints and survey results relating to pain management
 •       Drug test (if done and particularly if positive for substance(s)
 diverted)
 •       Personnel disciplinary action (particularly if issues re
 substance abuse or past medication errors or failure to document)
 •       Prescription Drug Monitoring Program (PDMP) report/
 prescription profile (particularly if the profile indicates a substance use
 disorder)
 •       Medical records of subject (particularly if being treated for
 chronic pain – pain management contract; noncompliant drug tests)
 •       Employee time records
Preparation for Drug Diversion Cases

            OTHER IMPORTANT EVIDENCE
   • Testimony of pharmacist, DON/CNO or other head of
   facility/hospital, prescribing physicians, or other witnesses
   (persons most knowledgeable – possibly also for rebuttal
   purposes)
   •      Testimony of other nurses (possibly also for rebuttal
   purposes)
   •       Law enforcement investigative reports (if available)
   •        Disciplinary action by another state BON or other
   licensing authority – especially if substance abuse issue or
   suspicion of or actual diversion (inference of past behavior
   indicating present – goes more to recommendation for
   disciplinary sanction)
Preparation for Drug Diversion Cases

             OTHER IMPORTANT EVIDENCE
   • Testimony of nurse (possible credibility issues)
   •        Psychological and /or treatment records of nurse
   (e.g., substance abuse evaluations, discharge summaries
   from treatment facilities -- particularly if information reveals
   admissions to diversion)
   •        Employment records of nurse from former
   employment (particularly if reveal personnel action related to
   actual or suspected diversion of controlled substances, or
   indications of substance use disorder)
   •       Documentation of occurrences since facility
   investigation completed
   •       Testimony/statements from patients (if available
   and strong recollection of Rx nonadministration)
Preparation for Drug Diversion Cases

         What to look for in Chart/Pyxis Audits:
 •       Frequent removal by override in Pyxis
 •       Withdrawal then cancels action in Pyxis
 •     Appropriate documentation of wasting or lack of
 documentation
 •       Waste and frequency of waste
 •       Waste without witness
 •       Frequency of medication and amount
 •        Correlation of removal activity with documentation
 •        Physician orders match medication administration to
 patient
 •        Documentation of pain assessment and control or failure to
 control pain despite continued administration of medication
 •     Date and time of medication administration comparison to
 MAR and nurse’s notes may vary
Preparation for Drug Diversion Cases

         What to look for in Chart/Pyxis Audits:
  •      Frequent new physician orders for different or stronger
  pain medication
  •       Administration of pain medications at frequent intervals
  above and beyond expected
  •       If range is ordered for medication, look for upper limits
  being administered and documented
  •       Review patient's pain range and usage on previous and
  following shifts
  •       Drug removal occurs at or shorter intervals as ordered
  •      Drug removal from other patients that nurse is not
  assigned or caring for
  •        Drugs are removed for patients no longer on unit or in
  hospital (e.g., patient moves from ED to inpatient unit or is
  discharged)
Preparation for Drug Diversion Cases

  Evaluating Medication Orders and the Nurse Who
              Administered Medication
 •Is a controlled substance (CS) signed out for a patient who has no
 order for the medication?
 •Does order authorize the amount of CS removed?
 •Does patient chart reflect assessment for administration of CS?
 •Do withdrawal times on sign out sheets or Pyxis report match the
 administration time on the MAR?
 •Was the patient/resident present when the medications were
 administered?
 •Did the nurse medicate another nurse’s patient?
 •Are another nurse’s initials forged on a MAR?
Preparation for Drug Diversion Cases

              Evidence of TYPES of Diversion
 •Signing out controlled substance but not administering to patient
 •Nurse ordering PRN controlled substances takes entire container
 when delivered
 •Switching tablets
 •Emptying capsules (substituting other substances)
 •Diluting oral liquid controlled substance with water
 •Diluting injectables with water or saline
 •Theft from emergency kits
 •Theft of discontinued controlled substances awaiting destruction by
 pharmacist or nurses
 •Dropped medication
Preparation for Drug Diversion Cases

Investigate the Pyxis or Automatic Dispensing System

                  POTENTIAL ISSUES
•Lack of reliability of automated system
•Lack of reliability of how automated system is used
•Lack of security or controls
•Lack of regular or routine checks and balances
•Lack of training for nurses using
•Lack of familiarity or investigation of “issues”
related to malfunctions, etc.
•Lack of “triggers” to prompt review for possible
discrepancies or irregularities
Preparation for Drug Diversion Cases

 Investigate the Pyxis or Automatic Dispensing System
•What are the recommended settings for the system used?
    • Understand the programming and options available
•What functions are “on”?
•What is available that is “off”?
•Why is it “off”? (how can this be detected?)
   • Understand the end user’s view
•Who authorizes access?
•What are the settings on access and exit?
•What are the different access levels?
     • How do these differ in different care areas?
•Who can override (and how/why)?
•Who can waste? (what system is in place?)*
Preparation for Drug Diversion Cases

         Possible Areas of Systemic Weaknesses
• User passwords not changed (bioprinting system available?)
• Users not terminated from system (access limited promptly?)
• Discharged patient list remaining available for hours or days after
  discharge (are alerts available?)
• Built in system controls “turned off” (too cumbersome)
• Overrides that permit removals without justification (documented in
  MAR?)
• Lack of internal controls over controlled substances stored in
  emergency kits for trauma or urgent needs
• Pain response documentation not regularly reviewed for patterns
• Inadequate segregation of duties
• Staff with no or little training/competency on system (poor practices)
Preparation for Drug Diversion Cases
Preparation for Drug Diversion Cases

          Additional Litigation Considerations
vWill formal discovery be required to obtain needed
  evidence?
• Objections to prosecution evidence
vWhat constraints may be faced in presenting at the hearing?
• Time constraints
• Limitations or availability of witnesses
vWhat creative methods can be used to present evidence?
• Use of demonstrative exhibits
• Power Point in closing
vCan a theme (theory of the case) be developed?
Preparation for Drug Diversion Cases
Preparation for Drug Diversion Cases

          Demonstrative Exhibits
Preparation for Drug Diversion Cases

                        CHARACTERISTICS
 ü Theory must be credible / believable
   " Consistent with facts
   " Explain away bad facts
 ü Theory must be interesting / entertaining
    " Non-abrasive or demeaning
   " Balanced with seriousness or sensitivity
 ü Theory must be consistent with common sense / human experience
 ü Theory must reveal the true nature / character of the major players
 ü Theory must lend itself to outcome
Preparation for Drug Diversion Cases
Preparation for Drug Diversion Cases
Preparation for Drug Diversion Cases
ØInvestigating staff/Board
  member
ØAttorney
ØHospital/Facility
  Personnel (DONs/CNOs,
  Drs., other nurses and
  Pharmacists)
ØOther agencies (law
  enforcement, Board of
  Pharmacy)
ØOther Boards of Nursing
Robert J. Walters
Senior Assistant Attorney General
Wyoming Attorney General’s Office
2424 Pioneer Avenue, 2nd Floor
Cheyenne, Wyoming 82002
307-777-8662
bob.walters@wyo.gov
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