Hospitals today seem to direct the bulk of their quality management resources towards publicly reported quality ratings and external awards for meeting and exceeding a pre-established set of safety standards. Recently, one hospital cited their quality and safety performance and awards as a defense when a diversion event was reported in the local newspaper.[i] Reading this article made me think about my experience in healthcare quality and safety. Hospitals may successfully apply quality management techniques to the limited list of quality and safety measures, but fail to spread the expertise into other aspects of the healthcare environment. We need to demonstrate the ability to consistently give care and treatment that meets patient expectations and legal/regulatory requirements. Patients should not have to fear receiving care from impaired providers, or be afraid of receiving tampered-with, contaminated medications. Once a diversion event occurs, a hospital may be faced with a plethora of problems ranging from loss of community reputation, a public health emergency, and/or massive fines and an onerous corrective action plan from the federal government.

When I was in a hospital quality/safety leadership position, drug diversion was not on our radar screen. We had a very engaged Board, and routinely provided education to the Board on quality and safety concerns. We had a laser focus on infection control and medication safety, but never linked the risks of patient harm from drug diversion to these important areas. Our focus was on managing the measures that mattered the most – the ones that affected our reimbursement. We conducted an infection control risk assessment every year which included community health data, but we did not consider the data about the rising opiate crisis in our community. How would that impact patient safety in the hospital? How would it affect the health of our employees who are part of that community?

If I could go back a few years, what would I want to tell myself about drug diversion prevention and detection? What would I do differently now if I was in that position as a leader? First, I would charter a multidisciplinary drug diversion oversight committee. The Committee would be charged with providing oversight for drug diversion prevention, detection, and diversion event management. The Committee would be aligned with the existing Quality and Safety structure to ensure that the drug diversion program has a high level of credibility and attention from the executive leadership and the board. Drug diversion is a patient safety issue and assigning resources to this important work demonstrates an organizational commitment to the hospital culture of patient safety.

Our team was very skilled in applying the techniques of Failure Mode and Effects Analysis (FMEA) to high risk processes of care. I would tell myself that the Diversion Oversight Committee should pull in the internal expert to lead them in a FMEA for controlled substance handling. The FMEA would include a review of policies and procedures and identify risk points from ordering, to receipt/storage/dispensing to preparation/administration and wasting. Using a risk-based approach driven by the FMEA data, we would use the Plan-Do-Check-Act cycle to change processes and eliminate risk points. Most importantly, I would ensure that we had a robust system of auditing the standard operating procedures. In many cases, our policies would need to be more specific in order to define expected safe behaviors, establish accountability, and be accepted by all participants.

We had no qualms about using consultants to help us see what had become familiar. Consultants were an important aspect of the accreditation compliance program – tracers done by trained eyes from outside the organization were able to help us find many risk points in our processes of care. Too often we implement procedures without testing, and our staff found myriad ways to work around the intended process, either because of supplies, efficiency, or lack of understanding the importance of specific steps. I would tell my former self to find a consultant that was an expert in hospital medication management, with in depth understanding of controlled substance handling across the organization. The risks of non-compliance with controlled substance handling should be considered significant based on recent findings from the Drug Enforcement Agency (DEA) against some large healthcare organizations. Even more important a find is the risk of a public health emergency when patients are given contaminated medications from tampered vials and syringes. The cost of consultants is far less than the financial, organizational and reputational risks of a serious drug diversion event.

In summary, leveraging the strengths of our hospital talent and strong safety culture would be my ounce of prevention now, and would hopefully prevent the need for a pound of future corrective actions. Don’t defer drug diversion prevention and detection process improvements – the time to act is now.



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