From the article:
Example #5: In order to discourage drug diversion in a neonatal care unit, and in the days before computerized fingerprint recognition, our nurses were required to do the following when retrieving medications from the Pyxis medication cart: The nurse fetching the medication would enter their password on the computer, remove the medicine from the Pyxis drawer, draw the correct amount, and administer it to the patient. If any medicine remained in the vial—which happened frequently, because newborns often require smaller doses—the nurse was supposed to call a second nurse to the Pyxis, who would enter their password. The second entry was supposed to indicate that the second nurse observed the first nurse discarding the left-over medicine. However, because the nurses resented having to bother one another, especially when they were extremely busy with patient care measures, they simply shared their passwords with one another and entered them when they returned to the Pyxis. Not only was this an easy shortcut, but it compensated for the nurses’ taking offense that administration would think them to be drug diverters. Of course, it categorically defeated the purpose of the regulation.
