Q & A with Aline Greene,
BSN, MHA, RN, CEN
Pharmacy Purchasing & Products: What should facilities consider when working to manage and prevent ADC overrides?
Aline Greene: Removing a medication from an ADC prior to pharmacy review and profile escalates the risk for error, as all safety reviews performed by the pharmacist are bypassed. Often routine actions, such as dispensing an antibiotic normally given to a laboring patient, can lead to overrides, but consider the one time when, in the hurried state of the patient laboring, the nurse forgets to double-check for allergies. One mistake of this type is too many. So, in order to ensure proper medications are removed from the ADC under controlled circumstances at our facility, we limit override capability according to specialty. Thus, a nurse’s ability to remove medications prior to pharmacy profile is limited to emergent medications specific to the area being served. We monitor override justifications on a daily basis, and nurse managers regularly discuss any issues with individual nurses.
As a result of reviewing monthly override reports facility-wide, we discovered process trends that were leading to systemic overriding. Delays during patient admitting and delays in scanning orders to the pharmacy, along with unreasonable nursing expectations as to appropriate profiling time—or actual pharmacy delays in profiling medications—all led to overrides. Once these overarching trends were identified, nursing and pharmacy both worked with the individual units involved to improve communication through these processes. To reduce overrides, nursing made scanning to pharmacy quickly a higher priority to allow pharmacists more time to profile medications. The ER admitting process also was changed so that patients’ room assignments were entered into the computer system earlier, allowing profiling and scanning of orders on arrival to the unit. As a result, we have experienced a steady decline in the frequency of overrides, yet continue to regularly monitor them.
PP&P: How can diversion from ADCs be prevented?
Greene: Diversion from ADCs is an ongoing concern that all hospitals using ADC technology must acknowledge and monitor. However, there is no single report sufficient to provide the detail needed to recognize controlled substance diversion activity. To approach this sensitive subject, our nursing and pharmacy leaders review a report that compares an individual nurse’s controlled substance administration to that of other nurses working in that area. If a nurse’s administration is two standard deviations higher than other nurses, we perform a full controlled substance audit of that nurse’s activity and report the findings to the nurse manager, director of nursing, and pharmacy manager.
One practice that raises a red flag is frequent use of the cancel function when removing controlled medications. If a nurse accesses a medication pocket, but the patient is not charged, he or she will usually point to the cancellation as proof that they did not remove anything. Other suspicious practices include frequent removal of non-narcotics at the same time pain medications are being removed, delayed wasting of controlled substances, and removing medications for multiple patients by one nurse at one time. While such actions are not necessarily evidence of diversion, they can be signs that education needs to be reinforced for activities related to medication handling through ADCs.
Ultimately, tracking controlled substance administration requires multiple reports and reviews of individual staff members to ensure policies and procedures are being followed appropriately and that signs of diversion are identified and resolved expeditiously. One of the best ways to monitor staff is to pay attention to comments and actions made during rounds, as important clues to staff behavior can be revealed in this setting.