Many federal and state laws, as well as national guidelines, have been established to protect public health and safety related to medication administration. This section will explain how federal and state laws, agencies, and guidelines protect patients from harm from medications.

Federal Agencies, Laws, and Guidelines

Food and Drug Administration

The United States Food and Drug Administration (FDA) protects public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices, as well as the safety of our nation’s food supply, cosmetics, and products that emit radiation.^[1] The FDA protects the public health by enforcing an official drug approval process based on evidence-based research and issuing Boxed Warnings for medications with serious adverse reactions. These actions are further discussed in the following subsections.

Developing New Drugs

American consumers benefit from having access to the safest and most advanced pharmaceutical system in the world. The main consumer watchdog in this system is the FDA’s Center for Drug Evaluation and Research (CDER). The center’s best-known job is to evaluate new drugs before they can be sold. CDER’s evaluation not only prevents quackery, but also provides doctors and patients the information they need to use medicines wisely. CDER ensures that drugs, both brand-name and generic, work correctly and their health benefits outweigh their known risks.

Drug companies conduct extensive research and work to develop and test a drug. The company then sends CDER the evidence from these tests to prove the drug is safe and effective for its intended use. Before the drug is approved as safe for use in the United States, a team of CDER physicians, statisticians, chemists, pharmacologists, and other scientists reviews the company’s data and proposed labeling. If this independent and unbiased review establishes a drug’s health benefits outweigh its known risks, the drug is approved for sale. Before a drug can be tested in people, the drug company or sponsor performs laboratory and animal tests to discover how the drug works and whether it’s likely to be safe and work well in humans. Next, a series of clinical trials involving volunteers is conducted to determine whether the drug is safe when used to treat a disease and whether it provides a real health benefit.

FDA Approval of a Drug

FDA approval of a drug means that data on the drug’s effects have been reviewed by CDER, and the drug is determined to provide benefits that outweigh its known and potential risks for the intended population. The drug approval process takes place within a structured framework that includes the following:

• Analysis of the target condition and available treatments: FDA reviewers analyze the condition or illness for which the drug is intended and evaluate the current treatment landscape, which provide the context for weighing the drug’s risks and benefits. For example, a drug intended to treat patients with a life-threatening disease for which no other therapy exists may be considered to have benefits that outweigh the risks even if those risks would be considered unacceptable for a condition that is not life-threatening.
• Assessment of benefits and risks from clinical data: FDA reviewers evaluate clinical benefit and risk information submitted by the drug maker, taking into account any uncertainties that may result from imperfect or incomplete data. Generally, the agency expects that the drug maker will submit results from two well-designed clinical trials to be sure the findings from the first trial are not the result of chance or bias. In certain cases, especially if the disease is rare and multiple trials may not be feasible, convincing evidence from one clinical trial may be enough. Evidence that the drug will benefit the target population should outweigh any risks and uncertainties.
• Strategies for managing risks: All drugs have risks. Risk management strategies include an FDA-approved drug label, which clearly describes the drug’s benefits and risks and information pertaining to the detection and management of any risks. Sometimes, more effort is needed to manage risks. In these cases, a drug maker may need to implement a Risk Management and Mitigation Strategy (REMS).

Although many of the FDA’s risk-benefit assessments and decisions are straightforward, sometimes the benefits and risks are uncertain and may be difficult to interpret or predict. The agency and the drug maker may reach different conclusions after analyzing the same data, or there may be differences of opinion among members of the FDA’s review team. As a science-led organization, the FDA uses scientific and technological information to make decisions through a deliberative process.^[2]

Boxed Warnings

As discussed in the previous section, the FDA approves a drug after determining that the drug’s benefits of use outweigh the risks for the condition that the drug will treat. However, even with the rigorous FDA evaluation process, safety problems can surface after a drug has been on the market and used in a broader population.

Boxed warnings (formerly known as Black Box Warnings) are the highest safety-related warning that medications can have assigned by the Food and Drug Administration. These warnings are intended to bring the consumer’s attention to the major risks of the drug. Medications can have a boxed warning added, taken away, or updated throughout their tenure on the market. Boxed warnings appear on a prescription drug’s label and in current, evidence-based drug references. For this reason, it is important for nurses to verify current drug information in drug references.

U.S. Drug Enforcement Agency (DEA)

The U.S. Drug Enforcement Agency (DEA) enforces the federal laws and regulations of controlled substances. This includes enforcement of the Controlled Substances Act (CSA) that pertains to the manufacture, distribution, and dispensing of legally produced controlled substances that nurses administer to patients.^[4]

Because controlled substances have a greater chance of being misused and abused, there are additional laws and procedures that must be followed when working with these medications. The DEA is responsible for enforcing these laws, and many federal laws are summarized in a document called the Pharmacist’s Manual. Most controlled substance laws, however, come from the state governments. Health care professionals are responsible for following the most stringent of the two laws, whether it be state law or federal law.

Examples of Federal and State Laws Regarding Controlled Substances

The following examples of federal laws are applicable to controlled substances administered by nurses.

• Prescriptions: A prescription for a controlled substance may be written only by a provider (physician or mid-level provider like a nurse practitioner) who has a DEA registration number. The prescription for a Schedule II medication (i.e., opioids) must be written or electronically sent to the pharmacy through DEA approved software. Prescriptions over the phone or fax are not accepted. Refills for Schedule II medication are not allowed and require new prescriptions. Schedule III or IV medications may be refilled only five times. State law determines how long a written Schedule II prescription is valid and if there are any limits on the quantity of medication that can be dispensed. For example, in Wisconsin, a Schedule II prescription is only valid for 60 days after it is written.
• Records: There is a “closed system” for record keeping of controlled substances to prevent drug diversion. Hospitals, clinics, and pharmacies must maintain records on the whereabouts of controlled substances from the time is received by the pharmacy, to when it is administered to the patient, to disposal of wasted medication by the nurse. Inventory counts of controlled substances occur frequently and may require a physical count by two RNs at the start of each shift. Detailed documentation is required for administration of controlled substances. When a full dose of a controlled substance is not administered, this is referred to as waste. Waste is typically disposed of differently than other medications (i.e., flushed down the sink) and often requires the co-signature of a second nurse.

Schedules of Drugs

The federal Controlled Substances Act (CSA) categorizes drugs regulated under federal law into one of five schedules. This placement is based on the substance’s medical use, potential for abuse, and safety or dependence liability. Schedule I drugs have a high potential for abuse and the potential to create severe psychological and/or physical dependence, whereas Schedule V drugs represent the least potential for abuse. An alphabetic listing of drugs and their schedule is located on the DEA website at “CSA Scheduling by Alphabetical Order.”^[6],[7] Sample medications for each schedule are included in Table 2.3.^[8]

Table 2.3 Definitions and Sample Medications for Each Type of Scheduled Medication

Drug overdose continues to be a public health crisis in the United States. The misuse of prescription opioids contributes to a large percentage of overdose deaths. Many problems associated with substance use are the result of legitimately made controlled substances being diverted from their lawful purpose into illicit drug traffic. The mission of DEA’s Diversion Control Division is to prevent, detect, and investigate the diversion of controlled medications from legitimate sources while ensuring an adequate and uninterrupted supply for legitimate medical, commercial, and scientific needs. The DEA provides education regarding related topics that apply to nurses such as drug diversion, state prescription drug monitoring systems, current drug trends, and proper drug disposal.^[9]

Drug Diversion

Drug diversion involves the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use. The most commonly diverted substances in health care facilities are opioids. Diversion of controlled substances can result in substantial risk, not only to the individual who is diverting the drugs, but also to patients, coworkers, and employers. Impaired health professionals can harm patients by providing substandard care or exposing patients to tainted substances.

Tampering is the riskiest and most harmful type of diversion. Tampering occurs when the diverter removes medication from a syringe, vial, or other container and injects themself with the medication. The diverter then replaces the stolen medication with saline, sterile water, or another clear liquid. The replaced liquid is then unknowingly administered the patient by an unaware nurse.^[10],[11]

The DEA provides an online reporting form for individuals to report suspected drug diversion anonymously. ^[12]

Substance Abuse Disorder in Health Professionals

Substance use disorder (SUD) is an illness caused by repeated misuse of substances such as cannabis, opioids, sedatives, and stimulants. Substances taken in excess have a common effect of directly activating the brain reward system and producing such an intense activation of the reward system that normal life activities may be neglected.^[14]

Health care professionals are not immune to developing SUD. It is important for nurses to be aware of the warning signs of SUD and to understand that SUD is a disease that can affect anyone regardless of age, occupation, economic circumstances, ethnic background, or gender. In most states, a nurse with SUD may voluntarily enter a professional assistance program for evaluation and treatment.^[15] Read more about professional assistance programs under the “State Law, State Nurse Practice Acts, and State Boards of Nursing” subsection below.

The National Council of State Boards of Nursing (NCSBN) created A Nurse’s Guide to Substance Use Disorder in Nursing brochure that states many nurses with substance use disorder (SUD) are unidentified, unreported, untreated, and may continue to practice where their impairment may endanger the lives of their patients. It can be hard to differentiate between the subtle signs of impairment and stress-related behaviors, but three areas to watch for suspected SUD are behavior changes, physical signs, and drug diversion. Behavioral changes can include changes or shifts in job performance, absences from the unit for extended periods, frequent trips to the bathroom, arriving late or leaving early, and making an excessive number of mistakes, including medication errors. Physical signs include subtle changes in appearance that may escalate over time, increasing isolation from colleagues, inappropriate verbal or emotional responses, and diminished alertness, confusion, or memory lapses. When nurses with SUD commit drug diversion, there are often discrepancies that colleagues notice, such as incorrect opioid counts, a pattern of large amounts of opioid wastage, numerous corrections of medication records, frequent reports of ineffective pain relief from patients assigned to that nurse, and patterns of increased administration of opioids when that nurse is scheduled to work.^[16]

As a student nurse and nurse, you have a professional and ethical responsibility to report a colleague’s suspected SUD to your supervisor and, in some states or jurisdictions, to the state board of nursing. The earlier that SUD is identified in a nurse and treatment is started, the sooner patients are protected, and the better the chances for the nurse with SUD to recover and safely return to work.^[17]

Drug Disposal Act

The Secure and Responsible Drug Disposal Act of 2010 allows users to dispose of controlled substances in a safe and effective manner. A Johns Hopkins study on sharing of medication found that 60% of people had leftover opioids they saved for future use; 20% shared their medications; 8% would likely share with a friend; 14% would likely share with a relative; and only 10% securely locked their medication.^[18] This act has resulted in “National Take Back Days” in all 50 states, as well as new collection receptacles.^[19]

Nurses should teach patients who are prescribed controlled substances how to dispose of them properly so that they don’t end up being misused or overdosed by another person. Figure 2.2^[20] shows an example of a controlled substances collection receptacle to prevent drug diversion.^[21]

The Joint Commission

The Joint Commission is a national organization that accredits and certifies over 20,000 health care organizations in the United States. The mission of The Joint Commission is to continuously improve health care for the public by inspiring health care organizations to excel in providing safe and effective care of the highest quality and value.^[22] Some of The Joint Commission’s national initiatives regarding medication safety include creating a “Safety Culture” in health care organizations with associated root cause analysis, the Speak Up Campaign, National Patient Safety Goals, and the Official Do not Use List. Each of these safety initiatives is further discussed in the following subsections.

Safety Culture

The Joint Commission Center for Transforming Healthcare develops effective solutions for health care’s most critical safety and quality problems with a goal to ultimately achieve zero harm to patients. Some of the projects the Center has developed include improved hand hygiene,^[23] effective handoff communications,^[24] and safe and effective use of insulin.^[25]

The Center has also been instrumental in creating a focus on creating a “Safety Culture” in health care organizations. A safety culture empowers staff to speak up about risks to patients and to report errors and near misses. These actions reduce the risk of patient harm. According to the Institute of Medicine, “The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.”^[26]  

A component of Safety Culture is the submission of incident reports according to agency guidelines whenever a medication error or a “near miss” occurs. A near miss is a narrowly avoided error. The incident report triggers a root cause analysis by the organization to identify not only what and how an event occurred, but also why it happened. When investigators determine why an error occurred, they can create workable corrective measures to prevent future errors from occurring.^[27]

An example of Safety Culture in action is a tragic event in 2006, when three infants died after incorrect heparin doses were used to flush their vascular access devices. A root cause analysis found that pharmacy technicians accidentally placed vials containing concentrated heparin (10,000 units/mL) in medication storage locations that were designated for less concentrated heparin vials (10 units/mL). Additionally, the heparin vials were similar in appearance, so the nurses did not notice the incorrect dosage until after it was administered. In response to a root cause analysis, the hospital no longer stores vials of heparin in pediatric units and uses saline to flush all peripheral lines. In the pharmacy, 10,000 units/mL heparin vials were separated from vials containing other strengths. In this manner, corrective measures were implemented to prevent future tragedies from occurring as a result of incorrect doses of heparin.^[28]

Speak Up Campaign

The goal of The Joint Commission’s Speak Up™ campaign is to help patients become more informed and involved in their health care to prevent medication errors. Speak Up™ materials are intended for the public and have been put into a simplified, easy-to-read format to reach a wider audience.^[29]

National Patient Safety Goals

The National Patient Safety Goals (NPSG) are established by The Joint Commission to help accredited organizations address current areas of concern related to patient safety. Annually, The Joint Commission determines the current highest priority patient safety issues with input from practitioners, provider organizations, purchasers, consumer groups, and other stakeholders and develops National Patient Safety Goals.

Two of the current National Patient Safety Goals relate specifically to medication administration: “Identify Patients Correctly” and “Use Medicines Safely.”

Identify Patients Correctly

Nurses and health care professionals must use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.^[31]

Use Medicines Safely

Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups, and basins should be labelled in the area where medicines and supplies are set up. Extra care must be taken with patients who take medicines to thin their blood (anticoagulants).^[32]

Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.^[33]

The Joint Commission’s Official Do Not Use List

The Joint Commission maintains an Official Do Not Use List of abbreviations. These abbreviations have been found to commonly cause errors in patient care. Accredited agencies are expected to not use these abbreviations on any written or preprinted materials.^[34]

CMS: Centers for Medicare and Medicaid Services

The Centers for Medicare & Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS). CMS administers the Medicare program and works in partnership with state governments to administer Medicaid. The CMS establishes and enforces regulations to protect patient safety in hospitals that receive Medicare and Medicaid funding.^[35]

CMS regulations related to the administration of medication by nurses include verifying information included in a prescription for medication, checking the rights of medication administration, reporting concerns about a medication prescription, assessing and monitoring patients receiving medications, and documenting medication administration. Each of these regulations is further discussed below.

Verifying Prescriptions

Medications are administered in response to a prescription from a health care provider or on the basis of a standing order that is subsequently authenticated by a provider. All provider orders for the administration of drugs and biologicals must include the following:

• Name of the patient
• Age and weight of the patient to facilitate dose calculation when applicable. Agency policies and procedures must address weight-based dosing for pediatric patients. Dose calculations for newborns are typically based on the metric weight in grams.
• Date and time of the order
• Drug name
• Dose, frequency, and route
• Dose calculation requirements, when applicable
• Exact strength or concentration, when applicable
• Quantity and/or duration, when applicable
• Specific instructions for use, when applicable
• Name of the provider

Checking The Rights of Medication Administration

The CMS states that agency policies and procedures must reflect accepted standards of practice that require specific information is confirmed prior to administration of medication. This is commonly referred to as “checking the rights of medication administration.”

When administering medications, it is essential for nurses to vigilantly check the rights of medication administration at least three times to prevent medication errors. What historically began as checking five rights of mediation administration has been extended to eight rights according to the American Nurses Association. These eight rights include the following^[36]:

• Right patient: Check that you have the correct patient using two patient identifiers according to agency policy (e.g., name and date of birth).
• Right medication: Check that you have the correct medication and that it is appropriate for the patent in the current context. Understand the purpose of the medication and why the patient is receiving it.
• Right dose: Check that the dose is safe for the age, size, and condition of the patient. Different dosages may be indicated for different conditions, and pediatric dosages are typically much lower than adult dosages.
• Right route: Check that the route is appropriate for the patient’s current condition.
• Right time: Adhere to the prescribed scheduling of the medication.
• Right documentation: Always verify any unclear or inaccurate documentation prior to administering medications.
• Right reason: Verify this medication is being administered to this patient at this time for the right reason. If signs and symptoms no longer warrant administration of the prescribed medication, notify the prescribing provider.
• Right response: After administering medication, the nurse must evaluate for expected outcomes with the time frame of expected onset and peak. The onset of medication administration occurs when the action of the medication begins to take effect. The peak of the medication administration occurs when the medication is at the highest level in the patient’s bloodstream. It is important for nurses to be aware of both the peak and onset of medications to know when the patient’s response to medication may start to be observed. The nurse must also be aware of potential side effects and adverse effects and evaluate for these unexpected outcomes. The prescribing provider should be notified if expected outcomes are not achieved or if adverse effects occur.

Many agencies have implemented barcode medication scanning to improve safety during medication administration. Barcode scanning systems reduce medication errors by electronically verifying the “rights” of medication administration. For example, when a nurse scans a barcode on the patient’s wristband and on the medication to be administered, the data is delivered to a computer software system where algorithms check databases and generate real-time warnings or approvals. Barcode scanning reduces errors resulting from administration of a wrong medication, incorrect dose, or wrong route. However, it is important for nurses to remember that barcode scanning should be used in addition to checking the rights of medication administration, not in place of this important safety process. Additionally, nurses should carefully consider their actions when errors occur during the barcode scanning process. Although it may be tempting to quickly dismiss the error and attribute it to a technology glitch, the error may have been triggered due to a patient safety concern that requires further follow-up before the medication is administered. Nurses must investigate errors that occur during the barcode scanning process just as they would do if an error were discovered while checking the rights of medication administration.

Communicating Concerns About Medication Orders

The CMS encourages hospitals to promote a culture in which it is not only acceptable, but also strongly encouraged, for staff to notify prescribing providers regarding concerns they have regarding medication orders.^[37] It is essential for nurses to contact the prescribing provider if they have any concerns when checking the rights of medication administration before administering the medication to the patient.

Monitoring Patients Receiving Medications

The CMS states that observing the effects medications have on the patient is part of the multifaceted medication administration process. Patients must be carefully monitored to determine whether the medication results in the therapeutically intended benefit and to allow for early identification of adverse effects and timely initiation of appropriate corrective action. Depending on the medication and route/delivery mode, monitoring may include assessment of the following:

• Clinical and laboratory data to evaluate the efficacy of medication therapy, potential toxicity, and adverse effects. For some medications, such as opioids, this monitoring may include clinical data such as respiratory status, blood pressure, and oxygenation and carbon dioxide levels.
• Physical signs and clinical symptoms relevant to the patient’s medication therapy, such as confusion, agitation, unsteady gait, pruritus, etc.
• Factors contributing to high risk for adverse drug events. The consequences of errors can be harmful and sometimes fatal to patients. In addition, certain factors place some patients at greater risk for adverse effects of medication. These factors include, but are not limited to, age, altered liver and kidney function, drug-to-drug interactions, and first-time medication use.

The nurse should consider patient risk factors, as well as the risks inherent in a medication, when determining the type and frequency of monitoring. It is also essential to communicate information regarding patients’ medication risk factors and monitoring requirements during hand-off reports to other staff.

Adverse patient reactions, such as anaphylaxis or opioid-induced sedation and respiratory depression, require timely and appropriate intervention per agency protocols and should also be immediately reported to the prescribing provider. An example of vigilant post-medication administration monitoring is a post-surgical patient who is receiving opioid pain medication via a patient-controlled analgesia (PCA) pump. Opioid medications are used to control pain but also have a sedating effect. Patients can become overly sedated and suffer respiratory depression or arrest, which can be fatal. In addition, the patient and/or family members should be educated to notify nursing staff promptly when there is difficulty breathing or other changes that might be a reaction to medication.^[38]

Documenting

CMS regulations require the agency’s documentation regarding medication administration contains providers’ orders, nursing notes, reports of treatment, medication administration records, radiology and laboratory reports, vital signs, and other information necessary to monitor the patient’s condition. Documentation of medication administration is expected to occur soon after the medication is administered to the patient; advance documentation is inappropriate and can result in medication errors. Proper documentation of medication administration and patient outcomes are essential for planning and delivering future care of the patient.^[39],[40]

State Law, State Nurse Practice Acts, and State Boards of Nursing

In additional to federal laws, regulations, national guidelines, and safety initiatives, state law also protects public health and safety. Each state has a Nurse Practice Act (NPA) that is enacted by the state legislature. The State Board of Nursing (SBON) enforces the NPA.^[41] The purpose of the SBON is to protect the public through licensure, education, legislation, and discipline regarding rules of conduct. The SBON regulates the licensure and practice of registered nurses (RNs), licensed practical/vocational nurses (LPN/VNs), and advanced practice nurse prescribers (APNPs).^[42]

Nurses are responsible for knowing the laws that relate to their nursing practice. Nurses must know and follow the scope of practice outlined in the NPA in the state in which they are employed. Nurses are accountable for the quality of care they provide and are expected to practice at the level of education, knowledge, and skill expected of someone who has completed an approved nursing program. Furthermore, all nurses are expected to recognize the limits of their knowledge and experience and to appropriately address situations that are beyond their competency.^[43]

Nurse Practice Act: Standards of Practice

The NPA outlines the standards of care provided by a registered nurse (RN), also known as the nursing process. An RN utilizes the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness, or care of the ill. This standard is met through the steps of the nursing process known as “ADOPIE. ” Review the steps of the nursing process in the “Ethical and Professional Foundations of Safe Medication Administration by Nurses” section of this chapter.

Nurse Practice Act: Rules of Conduct

The NPA also outlines rules of conduct expected of nurses. Nurses can receive disciplinary action from the SBON, ranging from a reprimand to revocation of their license, if they do not follow the enacted rules of conduct. A nurse must maintain current knowledge about expected rules of conduct in each state where they practice nursing to protect their nursing license.

A SBON may take disciplinary action against a nurse’s license for many reasons.  Common reasons related to medication administration include, but are not limited to, the following:

• Noncompliance with federal, jurisdictional, or reporting requirements, including:
  • Practicing beyond the scope of practice.
• Confidentiality, patient privacy, consent, or disclosure violations.
• Fraud, deception or misrepresentation, including:
  • Falsification of patient documentation.
• Unsafe practice or substandard care, including:
  • Failing to perform nursing with reasonable skill and safety.
  • Departing from or failing to conform to the minimal standards of acceptable nursing practice that may create unnecessary risk or danger to a patient’s life, health, or safety. Actual injury to a patient need not be established.
  • Failing to report to or leaving a nursing assignment without properly notifying appropriate supervisory personnel and ensuring the safety and welfare of the patient or client.
  • Practicing nursing while under the influence of alcohol, illicit drugs, or while impaired by the use of legitimately prescribed pharmacological agents or medications.
  • Inability to practice safely due to alcohol or other substance use, psychological or physical illness, or impairment.
  • Executing an order which the licensee knew or should have known could harm a patient.
• Improper supervision.
• Improper prescribing, dispensing, or administering medication or drug-related offenses.^[47]

State Statutes Related to Controlled Substances

State statutes are a compilation of the general laws of the state and often include chapters related to the state regulation of controlled substances (in addition to federal law).

Prescription Drug Monitoring Program

Many states have implemented prescription drug monitoring programs (PDMP) to help combat the ongoing prescription substance abuse epidemic, as well as to help prevent drug diversion. Pharmacies and health care providers are often required by state law to participate in a PDMP when dispensing or prescribing controlled substances. A PDMP is a statewide electronic database that collects data on substances dispensed in the state. By providing valuable information about controlled substance prescriptions that are dispensed in the state, PDMPs help health care providers make prescribing and dispensing decisions. PDMPs also foster the ability of pharmacies, health care professionals, law enforcement agencies, and public health officials to work together to reduce the misuse, abuse, and diversion of prescribed controlled substances.

Professional Assistance Programs

Many states offer professional assistance programs as voluntary, nondisciplinary programs to provide support for health professionals with substance abuse disorders (SUD) who are committed to their own recovery. The goal of professional assistance programs is to protect the public by promoting early identification of professionals with SUD and encouraging their rehabilitation and recovery. Professional assistance programs provide an opportunity for nurses with SUD to continue to be employed while being monitored by the SBON and supported in their recovery.