Utilize transaction reports and archival data prodigiously. ADC transaction tracking capabilities must be fully employed, both to optimize inventory and to uncover suspicious usage patterns possibly indicative of diversion. ADC reports providing statistical analysis of each user’s medication removals compared with other staff serving the same patient acuity should be run regularly to track dangerous trends, and archived data stored in the ADC should be mined consistently with software applications to reveal usage developments over time.
At Palomar Health, a public, two-hospital health system in northern San Diego County, the pharmacy departments use both statistical analysis of transaction reports and data mining to track patterns of ADC access on a monthly basis. When discrepancies are found based on this analysis, a detailed activity report is run as part of a more thorough investigation. The results—presented in a cover letter specifying what was found and what steps must be taken to resolve the problem—are forwarded to the nursing manager for speedy review and resolution. A 10-day turnaround window is required; pharmacy retains a copy of the cover sheet so that any delinquency in review time can be addressed with nursing management.
Beware of diversion of both controlled and noncontrolled medications. While controlled medications are an obvious choice for potential diverters—and hence monitored closely—pharmacy leaders should also be reviewing use of noncontrolled drugs. Evidence at our facility has shown that noncontrolled medications are also at risk for diversion and that additional controls should be put in place to properly manage their removal from ADCs. Examples have included oral broad-spectrum antibiotics and oral antifungal medications, which we suspect employees divert for the purpose of self-treatment. These medications have been placed on blind count.
Several of our pharmacy technicians recently voiced concern that the number of refills required for several noncontrolled drugs was higher than normal and that they had noticed an increased number of discrepancies in count during the refill process. In the ED ADC, recent removals of a noncontrolled pain medication (tramadol) and an antiemetic (ondansetron) have been higher than historic levels. Using data-mining software to run discrepancy reports covering a time frame of several months showed a large number of cancelled transactions. As a result, pharmacy met with nursing at a multidisciplinary medication management meeting, and suggested that placing these two medications on blind count would be prudent. Thereafter, we were able to carefully track usage and to identify the individuals responsible for diverting these two medications.
Make the move to biometric fingerprint identification. Biometric fingerprint identification provides an unparalleled level of security compared with password use. Because diverters will continue to devise new methods of circumventing technology, fingerprint identification should be adopted, as it is the method most likely to prevent unauthorized access to medications.
Few people have fingerprints that are unusable for ADC identification. Of the 2066 ADC users in our health system, only 10 individuals have unscannable fingerprints. These staff members are provided passwords that are changed quarterly. All of our ADC users are required to sign the same user agreement, specifying that they are responsible for all transactions performed under their user ID.
Proving its inherent value, biometric fingerprint identification recently revealed an incident of diversion from our ED ADC. The suspected nurse diverter had claimed that others were using her sign-on information and that she was not responsible for the diversion. However, using the biometric identification data on file, we were able to disprove her claim.
Enforce ADC investigation policy and procedure protocols. Occasionally, we have had difficulties with an inadequate response to pharmacy’s request for additional investigation of diversion. Our policy states that results of detailed activity reports forwarded to the nursing manager for further investigation must be addressed and returned to pharmacy with the results within 10 days. There have been instances in which the supervisor of in-house registry nurses, who is responsible for the pool nurses in both facilities in the health system, has not completed the necessary evaluation within the time allotted. This response was primarily due to the incorrect perception that little could be done, as the suspected diverter was a pool nurse that works in the other facility and is thus outside of the nurse manager’s purview. We are currently in the process of re-educating nurse managers and stressing the importance of closely monitoring employees in both facilities, including our substitute and fill-in nursing staff.
Actively track ADC withdrawals in high-traffic hospital departments. Medications stored in ADCs in busier departments, such as the ED, may require increased oversight. Restocking ED ADCs is particularly challenging at our facility, because medications are depleted quickly and it can be difficult to find opportunities to restock if the machine is in constant use. In addition, rapidly changing prescribing patterns make it hard to gauge what should be stocked in the cabinets. Monitoring diversion becomes more difficult because of these two factors.
When running reports to look for diversion patterns, the ED ADC users’ withdrawals from the machines are monitored as they are in other areas of the hospital. However, because medications removed from ED machines may look different than medications from ADCs elsewhere in the facility, we are careful to compare a user’s removals of medications to other users within the same busy area.
We have also scrutinized medication usage in the district’s EDs in other ways. Prior to CPOE adoption, the process at our smaller hospital was to evaluate ADC activity reports to ensure that the medications removed had a physician’s order attached to that removal. For example, using this method we were able to track errors related to confusion between diphtheria-tetanus (dT) and diphtheria-tetanus-pertussis (Tdap) vaccines and institute training to correct these errors.
At the point of CPOE adoption last year, the ADCs in the ED also were upgraded to include profiling capabilities; now, patient profiles are created in the ADC as the physician enters the orders. While an updated system inevitably presents fresh issues requiring resolution, we believe that the implementation of these steps has allowed us, along with ED nursing leadership, to create a safer medication distribution system in our emergency room areas.
Employ adequate staffing levels that allow effective, timely monitoring of ADC reports. Ensuring ADC reports are run regularly is important, but this step can only impact patient safety and diversion prevention if a sufficient number of staff is available to review the reports, evaluate results, and complete investigations of any discrepancies.
Our smaller facility has 107 beds and 15 ADCs. We have one part-time technician and several volunteers under her direct supervision monitoring use by 615 employees. At our larger, 319-bed facility, there are 33 ADCs. Three technicians work a total of about 40 hours per week to monitor use by 1450 employees; however, we feel that this staffing oversight is not quite adequate. Within the next fiscal year, we hope to hire a district-wide ADC specialist to assist existing employees in the crucial process of analyzing the use of our ADCs.
Bill Turner, RPh, is the pharmacy manager at Pomerado Hospital. He has served as a pharmacist for 30 years, 16 of which have been spent in both clinical and operational management. Bill obtained a BS in pharmacy from the University of Wisconsin-Madison.
Part 1 of a 2-Part Series: Elements of a USP <800> Compliant Cleaning Program
Conduct a Drug Diversion Investigation
Special PP&P Buyer's Guide: Temperature Monitoring
Develop a Pneumococcal Vaccination Program
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