Using some sort of software analytic tool has become standard practice in proactive diversion monitoring for hospitals and health systems. Reports are generated for anomalous use or standard deviations based upon transactions as a starting point for identifying potential diversion activity. This approach is fine but have you stopped to consider what is not included in these “numbers”? Let’s explore this question further and consider factors that may alter your thinking going forward.

First, consider that software analytics typically only cover controlled medications within automation. How are controlled substances stored within your operating rooms or procedural areas? The operating rooms have the highest use and transactional volume of all areas in the hospital, probably, combined. We put automated dispensing cabinets on every other patient care area but fail to cover the areas with the greatest need for surveillance. It is also probably safe to say the operating rooms and procedural areas have the least visibility to the pharmacy. So why the lack of automation within these environments? Often the initial response is “it is too expensive” but the cost of diversion and potential patient harm is typically much greater.

Okay, so let’s assume you have made the decision to not install automation in your operating rooms or procedural areas. You have made the decision to use kits or trays containing controlled substances for your providers. Are these kits or trays exchanged case by case or is the provider able to use them for an entire day? Remember that the entire time these controlled substances are outside of automation your analytic software is not tracking activity for them. How do you reconcile the kits or trays when they are returned? Frequently kits or trays are reconciled by comparing internal documentation against what has been returned by the provider. Best practice would include reconciling the internal documentation alongside the anesthesia or provider documentation within the electronic medical record. How and when are they returned? Some organizations have providers return unused medications for kits or trays to a “drop box,” further delaying the time to reconciliation. And, if returns do not include waste, how do you reconcile that record? “Taking the provider’s word” defeats your ability to detect potential diversion through the “culture of trust.” Again, best practice would include some form of random audit of returns to include refractometry or other chemical analysis to validate the liquid being returned is the drug and concentration stated by the provider. Keep in mind this entire paragraph of activity is happening outside your software analytics.

Clearly, lack of automation within the operative or procedural setting creates a large loophole in your proactive diversion monitoring program. To strengthen your program, step back and evaluate where there are gaps in your systems. Organizations frequently fail to realize weaknesses in systems that they see every day and have therefore become the norm. With a fresh set of eyes from the outside, system gaps and weaknesses often come into focus. For example, have you considered including anesthesia leadership in your discussion about how to better secure and monitor controlled substance activity within the operative and procedural settings? These colleagues may offer a different perspective to current systems and be able to recommend other possible solutions for consideration. Remember that drug diversion is not a “pharmacy-only” problem. Drug diversion is an organizational problem which needs to be tackled as a multidisciplinary issue.

A key message here is to recognize both the strengths and weaknesses of your software analytics tool. Our previous article “Drug Diversion Monitoring and Detection: Software Doesn’t Run by Itself”1 describes the pitfall of automating reports and blindly sending them out to nursing personnel who don’t understand how to use the reports. It is just as important for pharmacy personnel or staff charged with proactive diversion monitoring to understand what is NOT included in “the numbers” and to recognize where else they need to look for potential diversion.

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