Q & A with Brian C. O’Neal,
Pharmacy Purchasing & Products: What strategies have you implemented to monitor for diversion on your nursing units?
Brian C. O’Neal: Our drug auditing system generates a monthly hot list, which includes all users who have been flagged as having automated dispensing cabinet (ADC) transactions greater than three standard deviations above the mean when compared with others in their department. We review the drug auditing system and ADC reports to identify unusual transaction patterns and ADC users with controlled substance transaction patterns that make them outliers compared with their peers. We also do a number of audits to increase our odds of detecting diversion at the points of transfer, meaning person-to-person, machine-to-person, or person-to-machine transactions.
PP&P: How do you maximize the effectiveness of your reporting tool?
O’Neal: A reporting tool is only effective if it is used to its full capability. If pharmacy sends information on outliers to the nurse manager, but does not ensure that investigations are taking place, then the system is not being maximized. Ideally, pharmacy should oversee any inquiries, but regardless of who performs the analysis, accountability and follow-up are critical.
PP&P: How do you prevent diversion in units without ADCs?
O’Neal: In those areas, there are two key elements to diversion prevention and detection: limit controlled substance quantities that are available outside of an automated system and audit dispensing transactions. Whether you audit dispensings from the site to patients or from the pharmacy to the site, some level of auditing is necessary in the absence of automation.
PP&P: What is the best way to get nursing buy-in with pharmacy diversion management initiatives?
O’Neal: It is fairly easy for pharmacy to work together with nursing in diversion prevention if there is already a high level of trust and partnership between the two departments. In most institutions, pharmacy and nursing partner often on operational improvement initiatives, automation implementations, and medication safety efforts. With a cooperative relationship, diversion detection is simply a program whose goal is to ensure patient safety by identifying impaired practitioners. Without such trust, it is easy for nursing to view diversion detection initiatives as “pharmacy is out to get nursing”. Keep the focus on patient safety to develop a good partnership and an effective system will result.
PP&P: How can diversion be monitored in the OR?
O’Neal: The best approach is to establish an OR-based pharmacy service that handles all controlled substance dispensing and waste. Organizations without this luxury typically allow nonpharmacy practitioners to waste their own product, which increases both the audit load and diversion risk significantly. We audit the OR record against our dispensing/waste records to ensure all product is accounted for, and also perform qualitative analysis on returned controlled substances to validate identity.
PP&P: What strategies have you implemented to identify diversion within the pharmacy?
O’Neal: More audits, beginning with an audit of purchase transactions, should take place to detect diversion in the pharmacy. Purchase records should be routinely audited against records of receipt. Also audit transactions to and from the controlled substance vault, within the packaging area, and in the sterile admixture areas. Pay particular attention to how multidose vials and associated waste are handled. Another important audit involves reverse distributors handling expired controlled substances. This pass-off of ownership has to be closely monitored. We also pay a lot of attention to physical controls and security. Cameras, internal automation, and silent alarms should be employed to create a secure handling environment.
PP&P: What is the greatest challenge that you have faced monitoring for diversion?
O’Neal: There is a type of diversion that I cannot talk about for fear that someone will read this and try it. My second greatest challenge is the reality that our tools to detect diversion identify transaction outliers, meaning that a diversion practice usually has to have reached a point where it stands out or where an impaired practitioner makes a mistake to result in detection. By that time, the damage is already done to the practitioner’s life, and potentially, the lives of their patients. No matter how much time we dedicate to diversion prevention and detection, there is always going to be someone who is working just as hard to access controlled substances. Therefore, preventing diversion is a task that requires continuous vigilance.
PP&P: What steps should be taken when diversion is suspected?
O’Neal: Most institutions have a policy that allows them to perform a drug test for cause in these suspicious cases. More often than not, questionable transaction patterns are the result of poor practice (eg, inadequate documentation, mishandling of waste) rather than diversion, but in cases where one person is consistently flagged on the hot list, drug testing may be a good option. If an employee tests positive, several steps should be taken. Revoke access to secured areas and automation and ensure that all necessary disciplines have been notified. If the diverted quantity is deemed to be significant, then the incident must be reported to the Drug Enforcement Administration. Some accrediting bodies require all cases of diversion be reported directly to the institution’s CEO. It is a good idea to involve the police whenever diversion with intent to distribute is suspected, or if significant quantities were diverted.
PP&P: What should be done if a suspected diverter admits to medication theft?
O’Neal: Much of our response is dependent on the situation. Were they diverting for their own use, or was there intent to sell? Are they willing to accept counseling and treatment? There should be a discussion among all affected disciplines, human resources, and risk management to determine the next course of action. I have been involved in situations where diverters were relieved to have been caught, as they really wanted to get help with their addictions.
PP&P: What future plans do you have for diversion prevention efforts at your facility?
O’Neal: New technologies are emerging that allow for the merging of dispensing data with administration data. This provides easy identification of cases where a medication is removed from an ADC but never administered (ie, dispensing transaction without documentation of administration). RFID tracking also may have a future application in identifying controlled substance doses that leave the institution.
Brian C. O’Neal, MS, PharmD, graduated from the University of Kansas with a PharmD degree in 1998, receiving his MS in hospital pharmacy from The Ohio State University in Columbus in 2000. He has worked at the University of Kansas Hospital as assistant director of pharmacy for 11 years.