Detecting and Preventing Diversion

May 2020 : Diversion Management - Vol.17 No. 5 - Page #1

Q&A with Katelyn M. Hipwell, PharmD, MPH
Pharmacy Manager of Clinical Operations
University of Virginia Health System
Charlottesville, Virginia

Pharmacy Purchasing & Products: What is the top factor impacting the risk of diversion in the hospital setting?

Katelyn M. Hipwell: Controlled substance accessibility is the most significant risk factor contributing to diversion. Although hospitals must ensure that all necessary medications are available to meet patient care requirements, the risk of diversion requires that this accessibility be tempered with best practices, as well as technology and automation to help identify suspicious practices.

Controlled substance accessibility is influenced by the following:

  • Use of technology, including automated dispensing cabinets (ADCs), electronic health records (EHRs), and smart infusion pumps
  • Knowledge of and adherence to DEA and state regulatory requirements
  • Regular surveillance, reporting, and record-keeping
  • Active investigation of suspected diversion
  • Preserving the chain of custody
  • Controlled substance transaction auditing for all employees
  • A multidisciplinary approach that includes health care providers, support staff, patients, and human resources support
  • Pharmacy and therapeutics (P&T) committee-approved utilization and restrictions surrounding controlled substances

Accountability is vital to ensuring proper controlled substance management. Prioritizing employee and patient safety requires the development and enforcement of clear expectations for all staff.

One way to limit accessibility is to carefully review the criteria that determine which team members must have access to controlled substances. When such a review occurs on a regular basis, only those who truly require access will receive it. Note that team members include all staff at an organization who may come into contact with controlled substances, from the health care provider (physician, nurse practitioner, nurse, licensed independent practitioner, pharmacist, technician, etc) to environmental services staff, who could be at risk of committing inadvertent diversion from poor disposal practices.

PP&P: Who should be included in a diversion-prevention task force?

Hipwell: The University of Virginia Medical Center (UVAMC) developed a multidisciplinary diversion task force, which represents nursing (acute care, critical care, pediatrics, operating room, post-acute care, and procedural), pharmacy, providers, anesthesiology, human resources, toxicology, employee health, security, the faculty employee assistance program, informatics, the medication safety officer, medical center policy accreditation, and a process improvement coach. The team is tasked with establishing the criteria for data monitoring, evaluating current practices, and overseeing process improvement initiatives. Each one of these participants brings a unique perspective to the table.

PP&P: What diversion-prevention education and training is required for staff?

Hipwell: UVAMC has instituted standardized annual, large-scale education on controlled substance diversion, as well as hospital-specific processes, for all stakeholders. All new team members who will have access to controlled substances are required to complete computer-based learnings (CBLs; created by our ADC vendor) on controlled substance administration, accessibility, and proper use of ADCs. Further, all team members must review policies and practice area-specific standard workflows. Pharmacy and nursing directors, managers, and assistant managers must complete a controlled substance diversion monitoring education CBL that is specific to UVAMC.

PP&P: How can pharmacy gain administration’s support for investing in diversion-prevention resources?

Hipwell: Pharmacy leaders must cultivate a nuanced understanding of administration’s perspective in order to effectively convey the importance of investing in diversion-prevention resources. Communicating the results of key pharmacy reports will likely play a significant role in gaining administration’s buy-in for additional diversion-prevention efforts.

When requesting diversion resources, keep in mind that prevention efforts require both technological and human elements; strike a balance in order to maximize diversion detection, prevention, and response. When seeking resources, UVAMC focused on return on investment opportunities, decreasing waste in the system, and the capacity to provide increased patient-focused direct care.

Note that successful proposals for diversion resources may involve other stakeholders, such as the nursing and perioperative departments. Cultivating a strong partnership with nursing in particular is essential. One challenge we encountered was identifying the right individuals to champion diversion-prevention efforts. Because nursing was our strongest partnership, we invited them to the table to provide insight and feedback. Our champion was the administrator of nursing practice, education, and research. When choosing a champion, ensure that the individual chosen aligns with the pharmacy department’s stance on controlled substance management and diversion prevention. They should be passionate to drive initiatives forward, open minded to new tactics, and they must strive to achieve best practices.

The diversion task force discussed the improvements to our controlled substance surveillance program specifically designed to benefit nursing, such as time savings to complete an audit, eliminating the need to fill out spreadsheets manually, and less required email communication. Feedback from nursing early on in the process helped to shape the program to meet the needs of pharmacy and nursing and to propel the initiative forward.

PP&P: How can pharmacists help dispel the not-in-my-backyard phenomenon at their hospitals?

Hipwell: It is not uncommon for health care workers to believe that diversion happens at other facilities, but not their own. Because addiction is an equal opportunity problem, diversion has the potential to occur in every health care setting where controlled substances are used. Meet with staff to review studies that elucidate the hazards of diversion and the potential for it to occur in all organizations.

In addition, share data and information gathered by the pharmacy department on monitoring and quality improvement. Be sure to include unreconciled dispense data, which is the primary indicator that there could be a diversion problem at an institution. Such an approach will help build baseline knowledge and facilitate benchmarking against the hospital’s future practice.

Pharmacy should be familiar with the resources available to connect individuals to helpful recovery tools, both internally and externally. Gather information and form an action plan before acting on suspicion of diversion resulting from observation and/or data. The action plan must include employee assistance options that provide employees a pathway for support with addiction.

It is critical to note that culture change requires continual effort, or staff members will slip back into old habits.

PP&P: What is the value of utilizing technology to aid in diversion detection and prevention?

Hipwell: Because staff time is exceedingly valuable, it is prudent to invest in technology to detect diversion, rather than relying solely on the manual reconciliation of various data from multiple sources. In fact, ASHP guidelines on preventing diversion of controlled substances highlight the importance of utilizing automated technology in diversion management.1 By leveraging technology to complete the time-consuming rote tasks necessary for diversion detection, pharmacy will realize the added benefit of ensuring the accuracy of the information gathered, which also simplifies the data reconciliation process.

An interdepartmental team at UVAMC sought to establish standard metrics for controlled substance management. However, the lack of data reconciliation from all internal sources complicated this objective. Moreover, we lacked the time to properly complete this task. In response, the pharmacy informatics team developed automated processes to comprehensively integrate data from the EHR and ADCs while onboarding an analytics tool for machine learning and augmented intelligence assessment. The benefit of using machine learning and augmented intelligence technology is that it allows controlled substance surveillance to move beyond single method points of comparison and trending. For example, the system looks at multiple signals at once without having to run different reports to assess all transactions. The method for grouping team members is driven by patient type and patient care factors, and not purely by ADC location alone, which creates better comparisons to identify problem behaviors and diminish noise.

PP&P: What data should organizations track to detect potential diversion?

Hipwell: We know that each diversion case is unique and customized data may be required to complete an investigation; nonetheless, there are some standard EHR and ADC metrics that should be monitored on a daily basis:

  • Unreconciled dispenses and/or discrepancies
  • Undocumented wastes
  • Temporary patients
  • ADC biometric ID failures
  • User access (eg, level of ADC access for staff in various areas). When team members transfer positions, their access level must be changed based on their new role
  • ADC overrides and cancelled transactions
  • Complete reconciliation, from dispense to administration to waste

Note that data may not be captured for every transaction; ADCs may be on critical override or may experience planned or unplanned downtime, which can cause gaps. These gaps must be addressed by manually mapping the transactions during those periods of time and performing audits of those transactions.

Gathering the appropriate information to detect diversion typically requires sophisticated custom reports. Conversely, analytic software can be used to improve the accuracy of transaction reconciliation from dispenses to administration, without the need for creating or manipulating sophisticated custom reports.

Understanding how data is obtained is critical. Data quality can be improved by changing how it is input or by cleaning outputs. For example, we can adjust how EHR information is input. In our experience, pharmacy must spend a significant amount of time cleaning data on the back end due to entrenched practices associated with data input and limitations for changing these practices. Physician preferences need to be authorized, which can create challenges when trying to alter medications within order sets or on physician preference lists. Other changes to data inputs involve practice changes associated with different disciplines, which complicates the process. Therefore, it is not always favorable to change practices for the sake of better data inputs; there needs to be a best practice rationale besides cleaner data that drives practice change, or it is met with more resistance.

To measure the facility’s progress over time, it is vital to benchmark and share organizational data. When selecting metrics for regular measurement, consider whether the resulting data will support institution-wide performance assessments. Examples include:

  • Unreconciled dispenses
  • Unresolved discrepancies over 24 hours
  • Time from ADC retrieval to medication administration
  • Undocumented waste
  • Compliance with the institutional policy to complete ADC inventories daily

PP&P: What are some best practices for identifying and preventing diversion?

Hipwell: Best practices for managing diversion include the following:

    • Create a Multidisciplinary Team. Building strong partnerships with key stakeholders is essential to properly manage diversion. The team should be tasked with developing metrics, evaluating practice, and creating action plans for process improvement.
    • Interface with IT Colleagues. Building collaborative relationships with informatics staff is crucial to any technology implementation. This is particularly true when creating effective diversion prevention programs as any informatics limitations in the system will impact data accuracy and accessibility. Listen and learn from informatics colleagues, who might include pharmacy informatics and analysts, health system-level business intelligence, and data analysts.
    • Consider Process Mapping. Process mapping facilitates an honest evaluation of the organization’s current state and helps identify opportunities for consolidation or efficiency as well as any new steps necessary for improvement. To begin process mapping, visually map out the diversion-prevention strategy one step at a time. This will help define where, how, and what technology can be utilized and what other challenges should be prioritized to facilitate improvement. Process mapping should be incorporated into standard workflows and standard operating procedures. A sample process map is available in FIGURE 1.

  • Share Best Practices. Reach out to other organizations to share results and improve practices. Diversion affects all hospitals; sharing strategies for prevention with other institutions can benefit health care as a whole.

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Katelyn M. Hipwell, PharmD, MPH, is the pharmacy manager of clinical operations at the University of Virginia Health System in Charlottesville, Virginia.


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