Drug diversion by health care personnel is a crime whose victims include patients, the diverting staff member, colleagues of the diverter, the institution in which the diversion occurs, and the community. Diversion almost certainly occurs at every institution that handles controlled substances, and the rate of discovery of diversion events has increased steadily over the past decade.
Although regulations exist for diversion prevention and detection, as well as response mechanisms, ambiguity surrounding governance leaves many facilities grappling with exactly how to approach the issue and garner upper management support for a proactive program. Furthermore, institutional response strategies and issues such as confidentiality sometimes hinder open discussion. As a result, many facilities have separate internal standards for nursing and pharmacy and lack a uniform approach across institutions and across state lines.
Given the seriousness of the problem, a need exists for the development of tool kits, guidance documents, and training resources to help facilities build strong, standardized diversion-prevention programs. Health care institutions share the common goal of providing effective care in a safe environment. As such, they should be willing to collaborate and openly share best practices in the effort to identify measures that help ensure the safety of patients and staff, while reducing the risk of diversion.
Coalitions and Resources
If there is a silver lining to previous cases of patient harm due to diversion, it is that they have increased awareness of diversion and prompted the development of multiple stakeholder coalitions and resources for health care facilities, including:
The Minnesota Road Map (www.health.state.mn.us/patientsafety/drugdiversion/divroadmap041812.pdf) is in the form of a checklist. Assessment questions are organized into components including: organizational structure, access to data for reporting, facility expectations as demonstrated in culture and policies, and staff and patient education. A second section on medication handling covers drug storage and security, procurement, prescribing, preparation and dispensing, administration, wasting, monitoring of controlled substances, and the handling of suspected diversion. In all of these components, the road map emphasizes consistent processes and adherence to policies.
The Minnesota Toolkit (www.mnhospitals.org/patient-safety/collaboratives/drug-diversion-prevention) is a compilation of various resources for institutions, including a sample job description for a diversion-prevention coordinator, a list of Minnesota statutes and regulations related to diversion, a worksheet for monitoring records for evidence of diversion, a variety of educational resources, and links to websites and individuals with unique insight or expertise relating to diversion. All of the resources in the Minnesota Controlled Substance Diversion Prevention Coalition’s report can be applied or adapted to facilities in other states. In fact, many facilities around the country use the road map to perform an initial gap analysis in preparation for developing a robust diversion program.
Many entities have developed resources for addressing diversion and a vast array of information is available. At least partly in response to cases in which patients were harmed by health care personnel who diverted drugs, departments of public health across the US have created statewide multidisciplinary task forces devoted to providing tools for hospitals. Among the various resources are the following:
The coalition will be piloting the exercise in several acute care facilities within the state. The results of the self-assessments are expected to provide the coalition, and state and federal partners, with information on best practices and lessons learned, and enable the coalition to develop a facilitator discussion guide. In addition, the New Jersey One and Only Campaign posted numerous resources on its Web page, including print, audio, and video information; toolkits; posters; etc.
These excellent efforts undertaken by various states underscore the need for even greater standardization. Establishing best practices and providing access to effective diversion-prevention tools in a piecemeal fashion will produce limited benefits. Recognizing the need to move beyond the state-by-state approach and develop national best practices, professional organizations also have begun to tackle the issue of diversion by health care personnel.
There is substantial risk associated with diversion by health care personnel, as this activity endangers patients, while placing the lives and reputations of diverters at stake. Individual facilities should not fight the battle alone. By working together, health care facilities can develop strategies to reduce the likelihood that diversion will occur and address it effectively when it does.
Kimberly New, JD, BSN, RN, is a specialist in controlled substance security and DEA regulatory compliance and consults with health care facilities across the country. Kim works with health systems to establish and expand drug diversion programs with the overriding goal of improving patient safety.
Kimberly New is a frequent contributor to PP&P.
Her other articles include: