Drug Diversion: New Approaches to an Old Problem – Gregory Burger, MS, RPh, FASHP, and Maureen Burger, MSN, RN, CPHQ, CPPS, FACHE – Feb 2016
Regulations for hospitals have changed little since the Controlled Substance Act of 1970.
DEA investigators conduct scheduled investigations and unannounced visits to DEA registrants, ensuring that correct recordkeeping is being followed.
The agency has conducted several high-profile investigations in the last few years, resulting in multi-million dollar fines and organizationally significant corrective action plans.
In each case, the investigation was triggered by reports to the DEA of large quantities of missing or stolen doses of controlled drugs.
Upon investigation of the initial report, the DEA found other evidence of noncompliance with the regulations, especially around recordkeeping and supervision.
It is important to note that the lack of theft/loss reports may also act as a triggering event for a DEA visit.
I find this bizarre. It seems that either being too careless and having drugs stolen and being successfully vigilant to keep thefts from happening will both trigger the same DEA action. Since when does law enforcement go after people for committing “too few crimes”?
There are risk points for diversion whenever controlled drugs are handled, including ordering, receipt, storage, dispensing, administration, and waste.
Hospitals rarely audit their controlled drug management plan to assess for changes in practice or gaps in processes; good plans morph over time. Staff may deviate from the established procedures not realizing that they are creating risk.
The introduction of new technologies, such as automated dispensing cabinets (ADCs) and barcode medication administration (BCMA), often alter work flows without understanding the impact on access to controlled drugs.
The staff continually finds ways to work around the built-in controls, and some divert. The ADC programing allows the organization flexibility in how it uses the machine.
Essentially, there are 2 employee profiles that the organization should consider.
What do we know about the person who diverts controlled prescription drugs for personal use? They tend to be high achievers who are counted on and trusted by their colleagues, and they also tend to work extra shifts—more often the night shift.
They tend to work out of staffing agencies, and they may work in areas where there is more autonomy and less supervision, such as the operating room, intensive care unit, or emergency department.
In all cases, the common denominator is access.
Without active diversion analytics and documentation audits, their diversion activity may not be detected unless their performance at work begins to deteriorate, leading to patient complaints and staff concerns.
Diverting for personal benefit typically involves a large number of doses—more than an individual could reasonably use on their own.
The changing demographics in society today create new motivation to divert large quantities for sale.
This sounds like a reference to the current national climate of “despair”.
People can’t earn enough money to have a good life, so they drift into addiction. Then, they can’t afford their drugs of choice, so stealing becomes almost necessary. And when all else fails, these become the suicides called “deaths of despair”.
One example of large-scale theft was reported in 2014 when the director of pharmacy at Beth Israel Medical Center in New York City, was charged with stealing over $5.6 million worth of oxycodone.
Staff who work in environmental services, supply distribution, and other disciplines may come in contact with not only drugs, but also controlled prescription drug pads used to write prescriptions.
Employees with low-paying jobs may be motivated by offers from others outside the organization to steal drugs or prescription pads in exchange for large sums of money.
When nurses are encouraged to focus on physician satisfaction in lieu of patient safety, they are less likely to speak up and disagree; and when culture supports lax procedures for one class of staff, the other classes of staff may be prone to become lax as well.
Healthcare organizations frequently rely on a “culture of trust” as the foundation for diversion prevention. However, diversion prevention should be built on a foundation of checks and balances, with clear expectations for behavior and accountability.