Policy and Procedure for Random Drug Screens

Hi again!

Below is a general Policy and Procedure for the implementation of random drug screens for those healthcare workers with controlled substance access. This is a high level policy and more details would be needed before implementation, but it is a place for you to start. Let me know what you think…

Policy and Procedure for Random Urine Drug Screens:


Drug and alcohol screening is vital because an individual with patient contact that abuses drugs or alcohol may put employee and patient safety at risk and increase the frequency of negligence or malpractice claims.

Additionally, health care workers often have access to powerful prescription drugs, increasing the risk of on-site drug diversion.

To conduct a truly random drug and alcohol screening test, employers must use a statistically valid random generator.


To establish a policy governing periodic and random alcohol and drug screening of employees of XXXXX.


All employees of XXXXX with controlled substance access.


Diversion: Diverting a prescription drug for other than its intended purpose. In healthcare facility: Theft of medication, including “waste,” from patients or health care facilities for personal use.

Chain of custody: These are the procedures beginning at the time of collection to account for all handling and storage of each specimen.

Confirmatory test: A second laboratory procedure used to analyze a positive test result from a screening test. Gas chromatography/mass spectrometry (GC/MS) is the only authorized confirmation test.

Cutoff level: The concentration of a drug or drug metabolite in the urine at which a specimen is considered positive.

Medical Review Officer (MRO): A licensed physician who is qualified to interpret and evaluate test results and other relevant medical information.

Drugs Covered:

  • Alcohol
  • Cannabinoids
  • Cocaine
  • Opiates including fentanyl and oxycodone/oxymorphone
  • Zolpidem
  • Methadone
  • Amphetamines
  • Phencyclidine
  • Propoxyphene
  • Barbiturates
  • Benzodiazepines
  • Others as needed


Specimen Collection Procedures:

Once an employee has been selected for a random drug screen they will be tested prior to their next scheduled shift. Once notified of their selection, the employee has 5 hours to complete the test. Failure to submit a specimen for testing is considered a refusal to submit to a controlled substance test.

The area must be secure. The chain of custody form must be completed and sealed with the specimen. A copy of the chain of custody form will be maintained at the collection site and a copy will also be forwarded to the employee’s direct supervisor.

An employee’s direct supervisor should not serve as the collection site person unless it is impractical for any other person to perform this function. The collection site person is the individual that ensures that the urine specimen is collected according to required procedures.

Collection of urine specimens must be directly observed, the person must be of the same gender as the employee.

Once sample obtained, the temperature of the urine specimen is assessed to be certain it is within the normal temperature range (32.5°C, 90.5°-99.8°F).

A “split sample” of urine is collected. In the split sample method the urine specimen is divided into two containers. The purpose of the split sample is to allow the employee the opportunity to have the specimen retested at a different certified laboratory.

An employee must provide at least 45 ml (milliliters) of urine. Failure to provide an adequate amount of urine is considered a refusal to submit to a controlled substance test. If the employee is unable to provide the minimum amount of urine, the collection site person is to have the employee drink up to 24 ounces of fluid and try to provide a sample within two hours. If the employee is still unable to provide a complete sample, the test is stopped and the employee is sent for a medical evaluation to determine if there is a legitimate reason for failure to provide a specimen or there is a refusal to submit a specimen.

Laboratory Analysis Procedures:

The initial test is performed by an immunoassay test. The cutoff levels for screening tests are listed below and are expressed in nanograms per milliliter (ng/ml), or billionths of a gram per thousandth of a liter:

  • Marijuana metabolites 50 ng/ml
  • Cocaine metabolites 300 ng/ml
  • Opiate metabolites 300 ng/ml
  • Phencyclidine 25 ng/ml
  • Amphetamines 1,000 ng/ml

A confirmation test is performed on all initial positive tests. The cutoff levels for confirmation tests are:

  • Marijuana metabolites 15 ng/ml
  • Cocaine metabolites 150 ng/ml
  • Opiates
  • Morphine 300 ng/ml
  • Codeine 300 ng/ml
  • Phencyclidine 25 ng/ml
  • Amphetamines
  • Amphetamine 500 ng/ml Methamphetamine 500 ng/ml

The laboratory must retain the sample in frozen storage for a minimum of one year.

After being notified of a positive test result, the employee has 72 hours in which to request that the MRO have the specimen tested in a different certified laboratory.

Reporting and Review of Results:

A MRO examines all positive confirmed test results to determine if there is an alternative medical explanation for the positive test result. Before making a final decision as to whether a positive test is valid, the MRO provides the employee with the opportunity to discuss the test result. If the NMO determines there is a legitimate medical explanation for the positive test result, the MRO reports to the employer that the test is negative.






Again, this is just a start, more details will need to be determined and added. I would love to get your input…please comment!

About the Author

Kristin Waite-Labott is a registered nurse and recovering addict who has firsthand experience with the challenges of addiction. She now works as the Head Nurse Coach at Veritus, a virtual treatment program for nurses with substance use and mental health disorders, and is dedicated to helping nurses overcome addiction and making a difference in the lives of others. Kristin is passionate about addressing the growing problem of addiction among healthcare professionals and encourages open discussions and action to prevent it from spreading further.

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