Last month my colleague Greg Burger wrote about some everyday practices in the pharmacy that leave the door open for drug diversion. There are also everyday practices in nursing that create Access and Opportunity for drug diversion, and we have grown so accustomed to seeing these practices that we no longer recognize the risks. This is known as normalization of deviance and may be countered by increasing situational awareness of the risks. So, let’s review and become more aware.
Having been a surgical ICU nurse, it was not unusual to remove controlled substances from the automated dispensing cabinet prior to the patient arriving on the unit. It was highly valued to be prepared for the arrival from the OR, which meant that the drugs were ready to go. Unfortunately, the prepared syringes may have been tucked away on the counter or in the cupboard, which may or may not have been locked. Of course, being locked did not mean secure since the locks were all the same and we all had a key. Leaving controlled substances unsecured was an open invitation for tampering or outright theft. Easy due to access and opportunity, potentially difficult to detect.
Speaking of preparing controlled substances, how many of us would withdraw the medications from a Carpuject™? I did, which totally defeated the safety features of the prefilled cartridge – tamper resistance, tamper evidence, pre-labeled, and bar-coded. I never liked the cartridge holder, and the tip did not fit into a stopcock well, thus we “all” drew up the medication into a syringe. We rationalized the risks to patients (microbial contamination, med errors). Even worse when the medication was drawn out of the cartridge and injected into a prefilled saline syringe for dilution. So, easy for anyone looking to divert to pick it up and replace with a similar syringe. But don’t get me started on dilution of IV push medications – we’ll leave that for another post.
Another favorite practice that leads to wide open Access and Opportunity is when a nurse attaches a syringe containing a controlled substance to an injection port of a running IV. The rationale is that the nurse can give intermittent pulses of the medication into the running IV, thus controlling the rate of infusion but not having to stand there for the entire time. The reality is that the nurse may be interrupted, become distracted, or even leave the room during the medication administration. Recently this practice became more easily detected with the adoption of Simplist® prefilled syringes. Nurses reported that the syringe plungers were popping out when they left them unattended. Say what? This is not a design problem, this is a user error and a coaching opportunity to never leave a syringe unattended in a running IV.
Finally, let’s talk about controlled substance infusions. How many hospitals still deliver bags of morphine/fentanyl/midazolam to the ICU nurse, who signs a proof of receipt sheet, and then leaves the bag out on the counter, in the room, or hanging “un-spiked” on the infusion pump? Does the bag even have a tamper evident seal over the injection port? ICU patients are frequently surrounded by totem poles of infusion pumps, including controlled substances, but the nurse is not always at the bedside. Without proper controls, anyone with a needle and syringe can withdraw quantities of drug from the infusion bags without being detected. If this describes your practice setting, advocate on behalf of your patients to ensure that infusions bags are made tamper resistant, use IV tubing without injection ports, and secure the infusions until needed for use.
When at-risk practices such as described above are accepted, the organizational risk for drug diversion increases. Having an external set of eyes to review your practices and policies will help to mitigate risk points that are not “seen” even if they are in Plain Sight.