By Greg Burger, Vice President, and Maureen Burger, Chief Nursing Officer

For those who have dealt with drug diversion in hospitals over the years, it usually boils down to two factors leading to drug diversion (D2), Access + Opportunity. First, diverters will seek areas, shifts and settings where they have the greatest access to controlled substances or other drugs of diversion. Next, diverters will gravitate to where they have the greatest opportunity for diversion.

Access comes in many shapes and forms.

For some, access can be a clinical area where controlled substances are frequently used for legitimate purposes such as pain control, anesthesia or sedation. The most obvious locations are the operating room and recovery areas where care is in transition and oversight is low. Anesthesia providers have probably the greatest access of all personnel to the broadest array of controlled substances including fentanyl, sufentanyl, remifentanil, morphine, hydromorphone, midazolam and propofol (not controlled in every state but universally a drug of diversion by providers). In this environment, it is not uncommon for providers to prepare medications, including controlled substances for single or multiple cases that day, and store them in unsecured drawers. The anesthesia providers may cross cover for breaks and transfer control of medications that are drawn up for patient use, in syringes, and outside of automation or secured storage. Unsecured syringes may be stolen, tampered, and replaced by anyone with access to the operating room, including technicians, housekeepers, and nursing staff. The opportunity for diversion is especially high during room prep and room turnover when the anesthesia provider is absent.

At the end of the case, a nurse or another provider is asked to witness controlled substance waste… what is it you are really witnessing? If controlled substances are being wasted, how are they being wasted? If the controlled substance waste is transferred to the pharmacy for final disposition, how secure is the process and chain of custody? How is the pharmacy staff tasked with reconciling waste being monitored? Too often syringes or partial vials are either disposed of in open sharps containers or anesthesia waste bins, neither of which is tamper-resistant, or the drug is still retrievable. That’s right, waste stream is a problematic access point in many organizations. Hospitals have done a good job complying with EPA regulations but in the process forgotten to think about diversion as an issue with waste stream.

What about other access points? The most obvious is pharmacy itself. How are controlled substances handled when the pharmacy is preparing patient-specific infusions or syringes? What security, monitoring, and detection tactics are in place? Do you have checks, balances, and cameras in place to monitor for or prevent diversion? Is there an “angel’s share” of controlled drugs that are not accounted for when compounding? Are the prepared controlled substance products stored in a secure location – with camera surveillance? All of these are high-risk access points for diversion in the pharmacy.

Seeking out Opportunities

Now, let’s turn our attention to “opportunity.” Diverters are very intelligent about seeking out “opportunity.” Where would you gravitate to if you wanted to go undetected? Off-shifts such as midnights where there is less supervision and more patients per care giver? Float pool or traveler so you never stay in one spot long enough to raise suspicion on a unit anomalous usage report? The operating room or procedural area where the pace is fast and controlled substances are used in every case? Even in areas where automation such as dispensing cabinets and anesthesia stations are employed, diverters will survey the landscape and detect where drugs are outside of secure systems. How has your organization determined settings for system time-outs, blind counts and other security features? Too often the culture of catering to providers prevails and leaves gaps in the systems where diverters are quick to realize opportunity. Finally, consider the behavioral cues. In the pharmacy, is there staff who only wants to work with controlled substances – who volunteer to work extra or trade assignments? Or nursing staff who work excessive extra shifts – are these warning signs of potential diversion?

A final note on the waste stream – do you have large repository areas where waste containers are staged for pick up? Who has access and how would you know if something was missing? There are many stories about stolen sharps containers found above ceiling tiles during a facility renovation. How and why do you suppose they wound up in the ceiling? … Hmmm.

A + O = D2™

Have you accounted for Access and Opportunity when you built your drug diversion program (you built a drug diversion program, didn’t you?!). When was the last time you re-evaluated your risk points with a fresh set of eyes? You may want to consider an external review to identify risk points that go unnoticed because they are in plain sight every day and become part of the norm. In the end, you don’t have to be a mathematician to figure out the equation.

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