St. Joseph’s Hospital is an 886-bed community hospital located in Tampa, Florida. Part of BayCare Health System, St. Joseph’s has been using automated dispensing cabinets (ADCs) since October 1998 to manage the distribution and storage of medications, including controlled substances. Regardless of its distribution model, any hospital can be a target for diversion of controlled substances. Realizing mechanical controls alone were not sufficient to manage CII through CV inventory, St. Joseph’s implemented a computerized ADC reporting application in October 2005 to better monitor the flow of medications through our distribution process.
By automating ADC reporting, we have improved the tracking of CII-CV inventory through all aspects of the medication use system. To begin with, detailed reports on all controlled substance distributions help us identify any issues with the storage and/or delivery of those drugs from the pharmacy department. The application also provides a formal method for monitoring discrepancies at any ADC in the network, which is a default means to monitor for diversion. During the course of monitoring for discrepancies, it may become apparent a staff member is diverting, and may be working while impaired. In addition to fiscal and litigious risks for the institution, not to mention the criminal nature of diversion, impaired staff members can cause harm to patients, other staff, or themselves.
It is important to also consider the ramifications of diversion outside the work environment. After leaving work, an impaired staff member puts the general public at risk if operating a vehicle. Keep in mind that other than diverting for personal use, a staff member may divert to sell controlled substances illicitly. Not to be overlooked in light of public safety and patient care concerns, the loss of medications to diversion is a net financial loss for the pharmacy and the institution. Our computerized reporting application has allowed St. Joseph’s to improve oversight and accountability for controlled substances.
Reports for Discrepancy Management
Human beings are a clever and curious species. One of our defining characteristics is not only finding mechanisms and automation to perform tasks for us, but also discovering ways to defeat, and ideally, improve on such systems. Due to this, simply having automated systems for controlled or otherwise dangerous substances is not enough. St. Joseph’s found the combination of such systems with detailed reporting (not to mention personal, face-to-face contact and communication with staff) provides more thorough oversight and accountability. The number of reports available to screen for discrepancies allows the pharmacy department to closely monitor usage and access and track all distribution details for controlled substances. The following are examples of the reports St. Joseph’s generates:
If any of the above reasons are chosen, but do not make sense in explaining the discrepancy, a copy of the ADC report is sent to the nurse manager for further investigation. For unresolved discrepancies, an e-mail is sent to the nurse manager the following day as a reminder. This has proven successful over time to ensure resolutions are performed in a timely manner. With more than 85 ADCs in use, this has been shown to be an effective process for follow up at St. Joseph’s.
Using an Online Data Management System
To help manage long-term oversight, St. Joseph’s moved to an online data capture and analysis application. The daily archives of actions performed at ADCs are automatically uploaded to a server to ensure files are current. While many years of data can be stored, St. Joseph’s has elected to retain the prior 365 days in an electronic folder to use for convenient reporting.
A bimonthly anomalous usage report is printed and sorted by facility and individual ADC. The dual report is analyzed to identify ADC users who remove significant quantities of controlled substances compared to hospital-wide users, and compared to team members working in the same patient care area. If a particular user stands out above an expected or reasonable number of removals, the individual’s manager is contacted to review patient records. If this review demonstrates actions above and beyond the course of proper protocol, the human resources department is contacted.
In addition to routine reports, the online data management system is also useful for examining a specific employee’s use of ADCs. If a team member exhibits warning signs of impairment (see sidebar on page 8) a report is run immediately.
Online data management can also provide key assistance with managing non-controlled medications stored in ADCs. Analyzing various components of the distribution process—removals, par levels, stockouts, refills, etc—can help optimize inventory management. From a cost standpoint, more than a third of the pharmacy inventory at St. Joseph’s is stored in ADCs. With such a significant amount of drug inventory held in these satellite units, the reporting capabilities of an online data management system have improved St. Joseph’s ability to automate inventory management and optimize the storage and monitoring of non-controlled substances in ADCs.
By taking a collaborative approach, the nursing and pharmacy departments can effectively manage controlled substance inventory, distribution, and administration, and the documentation of waste. The vast majority of health care employees come to work every day and perform their duties in a professional, accurate, and honest manner. However, it is essential for all organizations to have oversight and safeguards in place to ensure controlled substances are used and tracked appropriately.
See St. Joseph’s policy for controlled substance management (at the end of the article).
Ira Kurland, RPh, has been coordinator of automated patient medication systems in the department of pharmacy at St. Joseph’s Hospital in Tampa, Florida for the past 13 years. Ira received a BS in pharmacy from St. John’s University in Jamaica, New York.
Tim L’Hommedieu, PharmD, MS, is pharmacy manager at St. Joseph’s Hospital. He completed a PGY1 and PGY2 residency in health system
pharmacy administration at Nationwide Children’s Hospital and received a PharmD and MS from The Ohio State University.
Possible Diversion Warning Signs
Diversion is an issue at every hospital; therefore, the pharmacy department should work closely with nursing managers to identify significant changes in job performance, personality, or work schedule. Such changes often can supplement the discovery of discrepancies in identifying diversion, and to properly monitor staff, managers must be aware of the possible warning signs. Consider the following behaviors or conditions when reviewing groups or individual staff members in departments where diversion has either been identified, or is suspected.
Personality or Mental Status
Other Signs of Potential Diversion
St. Joseph’s Policy for Controlled Substance Management
The purpose of this policy is to provide a written process to facilitate the management of controlled substances in our ADCs and to prevent unauthorized use.*
1. The override process inherently bypasses an important safety step in the medication use process and should be utilized only in an urgent/emergent situation in which the care of the patient would be compromised if the medication were not administered immediately.
2. If a patient is not yet in the ADC system (eg, a new patient), an override may be avoided by writing the patient name, account number, and room number on the physician order sheet and scanning to pharmacy.
Daily: At the end of each shift the charge nurse or their designee will check the ADC for a discrepancy icon.
ADC Reconciliation Process
Weekly: Two nurses perform inventory and document completion
of the inventory by signing the controlled substances log.
The unit/department manager is responsible for the oversight process, by:
Proactive Evaluation Process
Level 1: Evaluate the proactive diversion report sent from pharmacy when a concern is noted in the initial pharmacy screening.
(Note: If a staff member exhibits behavioral signs and symptoms of possible diversion, the manager should also initiate a Level 2 investigation).
Level 2: Investigation will include pharmacy and manager review of detail reports for inconsistencies, trends, and/or suspicious events. If found, proceed to Level 3.
Level 3: Notify Team Resources.
The Level 3 investigation may include manager review of medication-
related documentation on a sample of 8 to 12 charts (physician orders, MAR, nursing notes, pain scores, etc). Reasonable suspicion indicators may include medications withdrawn from ADC without documentation on MAR or lack of correlation between MAR and nurse’s notes. If found, proceed to Reasonable Suspicion Investigation.
Level 4: Reasonable Suspicion.
If Reasonable Suspicion is found, convene Team Resources and HR for next steps.
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