Preventing drug diversion, especially regarding controlled substances, is an important role for pharmacy management. This is especially true considering that up to 15% of healthcare professionals will misuse substances during their careers, a statistic that matches the general population. However, pharmacy is often in the reactive position of responding to diversion that has already taken place, sometimes weeks or months after the actual event. This complicates and impedes pharmacy’s ability to prevent and quickly address diversion problems. A robust diversion-control program requires resources and tools to be both efficient and effective. Many times, this involves the rollout of technology.
Although pharmacies use a variety of strategies to prevent diversion, methods for achieving this can be inconsistent and best practices are not universally followed. The most common methods for preventing diversion are based on personnel management: almost 80% of inpatient pharmacies conduct audits of controlled substances against medication administration records (MARs), and around 72% assign different staff to ordering duties vs. receiving duties for controlled substance orders. Meanwhile, only 63% use diversion detection software and even fewer use monitored waste disposal systems for controlled substances.
Diversion can occur throughout all steps of the medication-use process, which includes procurement, storage, prescribing, preparation/dispensing, administration, and waste/destruction. Some technologies can be used throughout all parts of the medication-use process to minimize diversion. This includes the use of cameras as well as computerized medication systems to facilitate audits. However, other technologies are best suited to one or more steps of the process.
Automatic Dispensing Cabinet Software to Prevent Diversion
Automatic dispensing cabinets (ADCs) are an important part of diversion control during the administration and wasting/destruction processes. Access to controlled substances can be limited by setting low par levels within the ADC. This both minimizes the risk of diversion as well as ensures frequent restocks will be required, increasing the chances that any diversion or discrepancies would be quickly caught.
ADCs can also generate reports to provide documentation and track usage. For example, the ADC can generate alerts when a member of staff has abnormal activity compared to their peers.
Further, audits on ADCs can be run jointly with audits on MARs, to ensure that any controlled substance dose removed from the ADC was administered promptly to the patient, minimizing the chance for diversion. These audits can also encompass checking the substance against both prescribing and dispensing documentation. Many ADCs can integrate directly with the electronic medication record (EMR) to facilitate this, optimizing pharmacy workflow and efficiency.
Some ADCs even generate null transaction reports when multiple substances are removed at once. This can be useful to assess diversion risk if, for example, a tablet of ibuprofen and a tablet of tramadol are removed simultaneously, as the patient may be given the ibuprofen instead of the tramadol. In the future, some ADCs may even be able to incorporate pain scores into this process, to ensure that PRN narcotics are being taken from the ADC only when the pain score supports this per the medication orders.
ADCs are also central to the wasting process. ADC software can track not only wasting patterns but also witness patterns. For example, a staff member who wastes narcotics and always selects the same witness may be flagged, as repeated combinations like this can increase the risk of both staff members being party to diversion.
Cameras to Prevent Diversion
Many pharmacies already have cameras in the controlled substances vault, which is a high-risk location for diversion during the procurement and dispensing processes. Other high-risk locations should also be prioritized for camera installation. These include anesthesia and procedural rooms, emergency departments, surgical centers, and remote locations.
Because diversion can occur directly from ADCs, these should also be considered for camera monitoring. ADCs can be physically moved to a central primary work area, ideally one covered by cameras, so that access to the ADC can be visually monitored. In this way, multiple technologies – both the ADC and camera technology – can be used jointly to minimize diversion risk.
Automated Software Systems for Diversion Prevention
Software systems can integrate electronic data from ADCs, EMRs, infusion pumps, electronic prescribing, payroll systems, and inventory to review the entire medication-use process for diversion. Because many of these systems organize, analyze and present this data on a dashboard or other easy-to-read format, pharmacy efficiency is maximized while data are tracked and presented in real-time.
Further, because the collected data is presented in simple and understandable formats, more stakeholders can become involved to review findings and anomalies. In the past, such data often needed to be manually collected and entered into a spreadsheet by trained pharmacy personnel. Newer software, however, not only tracks data quickly and accurately but also frees pharmacy staff to focus on other issues.
Sample alerts can range from informing management of an unexpectedly low volume in a controlled substance infusion that should have had a greater volume, to discrepancies in reconciliation between controlled substance orders and quantities available in the vault.
Getting Stakeholders On Board with Diversion Prevention Technology Initiatives
A variety of hospital stakeholders should be involved with diversion prevention programs. This includes representatives from nursing, anesthesia, risk management, general counsel, employee assistance program, human resources, security, environmental health and safety, compliance, regulatory, information technology, and pharmacy. A Controlled Substance Diversion Prevention Program Committee should be formed and tasked with surveying internal data, including internal diversion cases as well as assessing national diversion cases and resources available at other organizations.
Some organizations have then further subdivided committees into focusing on diversion surveillance policy, diversion response policy, and electronic prescribing policies. Organizational risks can then be identified based on gaps, and interdisciplinary task forces can be assigned to make recommendations. If additional support is needed to make the case to decision-makers about the need for robust diversion control, external consultants can be hired to help.
Schneider, Philip J.; Pedersen, Craig A.; Scheckelhoff, Douglas J. “ASHP national survey of pharmacy practice in hospital settings: Dispensing and administration—2017,” American Society of Health-System Pharmacists, 2018.
Barta, Blake T.; Vest, Tyler A. “Drug Diversion Identification and Prevention Strategies,” Pharmacy Purchasing and Products, January 2021.
Desai, Nilesh. “Automating Proactive Diversion Monitoring,” Pharmacy Purchasing and Products, n.d.
Gilchrist, Neil A. “Strategies for a Comprehensive Diversion Program,” Pharmacy Purchasing and Products, September 2021.
American Society of Health-System Pharmacists. “ASHP Guidelines on Preventing Diversion of Controlled Substances,” 2017.
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