Prescription drug diversion within healthcare facilities, particularly controlled substances, is a growing concern across America. The numbers are startling: more than 7 million non-medical users of prescription drugs are estimated to be addicted to prescription medications, and approximately 12-16 percent of healthcare professionals will be addicted to a prescription drug at some point during their career. This is a very costly problem for the U.S. healthcare industry, with the treatment costs to medical insurance companies estimated at $73 billion annually.1
In 2008, Saint John's Regional Medical Center, Oxnard, CA, reviewed several cases related to staff drug diversion. The hospital leadership responded by performing a thorough investigation of their drug diversion policy, aimed at protecting patients and identifying diverters among its clinical staff.
The hospital now performs random audits among clinical staff to track medication withdrawals from the Omnicell automated dispensing cabinets (ADCs), and monitors behavioral trends of providers' withdrawals by using integrated data analytics software from Pandora Data Systems.
Using Omnicell and Pandora, the hospital can generate actionable reports, a time-saver that allows clinician leaders to pull relevant user information and identify potential drug diversion. The hope is to be able to identify at-risk individuals early, in order to protect patients and help put diverters on the road to recovery with rehabilitation while preserving their professional careers.
The Audit Process
From the beginning, the executive leadership at St. John's committed to identifying drug diversion with an aggressive audit process that randomly selects ADC users to be screened weekly to determine if the medications removed from the cabinets for a particular patient are, in fact, documented as being given to the patient. As a user, the simple fact of knowing that you are being monitored on a regular basis increases compliance, minimizing opportunities for diversion.
The audit process begins by running a Dispensing Practice Report from the ADC Report menu and reviewing the activities of the healthcare professionals. From that report, a random group of 30-40 nurses is selected for more detailed analysis of their activities.
From this list, a report is run on each user using the Pandora Data System's software. This particular report lists all the transactions that were conducted by the specific individual and includes patient name, room number, time of transaction, visit ID number, medication name, amount vended, amount wasted, if any, and any witnesses who may be required for the waste/override transactions.
Key audit points include:
- Was there an order for the controlled substance?
- Was the nurse who took the controlled substance from the ADC assigned to the patient who received the drug?
From the data reports generated by both Omnicell and Pandora, the electronic reports are then reviewed for cases in which there is not a clear answer to either of these questions. These "fallouts" are then entered into a report that is sent to the nurse manager for follow-up within 24-48 hours. When there are not clear explanations for the discrepancies, the individual is interviewed to ascertain the reason for the inconsistencies.
Healthcare professionals improperly divert controlled substances for a variety of reasons, but in approximately one out of three cases, the reason is tied to a family problem. Difficult personal family issues the clinician may be experiencing, along with access to prescription medications at their workplace, can be a stimulus for addiction to painkillers.
We see clinicians facing situations such as:
- There is a crisis in the clinician's family and the drugs are taken for personal use with the belief that they are needed to get through the crisis
- The drugs are diverted for another member of the family who needs them
- There is a family economic crisis and the drugs are being diverted to sell them
As part of the drug diversion policy, St. John's nurses and other healthcare professionals identified in such circumstances are given a choice: either accept the hospital's offer to provide therapeutic help or their employment is terminated.
Key Roles Within the Medication Safety Team
St. John's drug diversion policy is only accomplished by a committed clinical staff and hospital leadership supporting drug diversion as part of its goal to empower their clinicians to offer patients the highest level of care. The roles of key medication safety team members in the drug diversion audit process are as follows:
- Director of pharmacy: Performs the audit, assess the results and take necessary actions to resolve discrepancies.
- Chief nurse executive: Ensures that nurses promptly comply when the director of pharmacy asks for explanations of audit findings.
- Quality manager: Evaluates the audit's usefulness as a performance improvement program; maintains statistical records.
As a result of audit findings, cases of identified diversion are reported to the hospital's CEO, the Drug Enforcement Agency (DEA) and, for St. John's, the California Board of Pharmacy, the California Department of Public Health and the California Board of Nursing if a nurse is involved.
Other focus areas in the prevention and management of drug diversion include monitoring the following tasks:
- Controlled substance counts in the ADCs are required at each shift change.
- The hospital requires a witness for any controlled substance transaction defined as an override.
- Reports focus on tracking the time the drug arrives at the facility to when it enters the pharmacy ADC system.
- Patients' signs and symptoms, such as a patient receiving increasing amounts of pain medications but not getting relief, are examined.
No hospital is immune to drug diversion. With a solid medication monitoring program supported by a committed clinical staff, early detection can prevent putting patient safety at risk. One of the biggest barriers to stopping drug diversion is proper reporting tools implemented and used at the hospital. Prevention measures and proper reporting of drug diversion to authorities is critical to reducing diversion and protecting patients.
1. Sobel, M.G. (2008). A comprehensive guide to preventing controlled substance diversion. Pharmacy Purchasing & Products, 2(6), 16-18
Richard Carvotta is director of pharmacy services at St John's Regional Medical Center, Oxnard, CA.