Identifying and dealing with drug diversion

According to the Drug Enforcement Administration (DEA), nearly 7 million Americans are abusing prescription drugs — more than the combined number of those abusing cocaine, heroin, hallucinogens, ecstasy and inhalants — representing an 80 percent increase since 2000. According to the SAMHSA.gov Web site, substance abuse costs businesses $100 billion annually due to productivity loss, absenteeism and insurance premiums.

However, it is surprising to note that prescription drug abuse reaches beyond patients and often affects the very practitioners entrusted with delivering the medication. Healthcare professionals are some of the most common abusers of prescription pharmaceuticals, which correlates with their easy access to the medications during the normal course of their duties. There are two aspects to drug diversion: (1) the direct and indirect impact on a patient's care if the patient does not receive the medications that his or her physician intended, and (2) the impact on the healthcare worker who develops a pattern of drug diversion. Hospitals want to keep their patients safe and eliminate the opportunities for employees to divert medications and potentially jeopardize their jobs. Early detection can allow hospitals to correct employee behavior before it becomes necessary to impact their employment.

Drug diversion can occur in all clinical areas, including: falsification of medication administration documentation, replacement of a vial of a controlled drug (e.g., morphine) with saline, excessive wastage (without actual witnessing), shorting doses of patient medications, substitution of non-controlled drugs, discrepancies between actual vs. system medication counts and intentional miscounts (both restocking on the floors and the central pharmacy and activities within stores and the vault). One study showed that drug diversion could be as high as 18 percent among nurses. However, diversion goes beyond nurses to include physicians, pharmacists and any other employee involved in handling controlled substances.

No hospital is immune to drug diversion, but there are proactive steps that can help detect diversion before it becomes an issue of patient safety. In an effort to meet regulatory compliance and prevent diversion, most hospitals have implemented automated dispensing cabinets (ADCs) to provide physical control and limit authorized access using biometrics and bar coding. More recently, hospitals are increasingly using special software technology for medication surveillance.

The challenge for hospitals is to stay a step ahead of drug diverters. Even with secure cabinets, some diverters have found ways to subvert the system by removing doses for patients who do not require a dose, but still documenting as an administered dose.

While ADCs effectively control access to medications, many of these systems lack the comprehensive reporting functions to identify all possible methods of drug diversion. Most ADCs offer some reporting functions, but accessing and running the reports is often time consuming. The reports themselves are not always easy to navigate, and identifying diversion trends can be difficult.

To address this concern, several companies are offering compatible software programs to run data reports on ADCs to monitor medication-usage patterns. The software helps identify potential diverters, building a safe and secure environment for patients. One of the leading medication-usage reporting tools is from Pandora Data Systems, which leverages hospitals' existing ADCs and integrates the import process into the work flow. While tracking each pill that is dispensed, administered and returned to the ADC system, the new PandoraVIA solution is also able to receive drug administration from a hospital's electronic medication administration record (eMAR) system to look specifically at dispensing and drug delivery discrepancies.

For a drug-diversion prevention program, Pandora's Anomalous Usage Reports, Discrepancy Reports and Activity Reports are effective tools that allow hospital staff to examine ADC activity trends. By accessing data from the ADC or using real-time HL7 interfaces from the ADC to Pandora, hospitals can run reports to show medication-usage trends for the entire hospital and identify individuals with transaction anomalies worthy of further examination. The Pandora solution reduces the time spent on collecting data and generating reports, while allowing hospitals to more effectively identify potential diverters. Since the data is easily accessible, reporting tools also help improve the auditing efficiency and meet the increasingly stringent regulatory compliance requirements of The Joint Commission and the DEA.

Case study: Prevention methods
In June 2009, a report of Boulder Community Hospital in Colorado made headlines when the hospital announced 108 instances of theft and tampered fentanyl vials taken from automated dispensing equipment. The report indicated that a nurse had been replacing fentanyl with saline, often referred to as substitution of medication, and the diversions potentially involved more than 350 patients over a one-month period. The investigation began when anesthesiologists became aware that surgical patients did not appear to be receiving enough pain medication.

Unfortunately for hospitals and health facilities, it is only a matter of time before drug diversion will occur. If hospitals have a medication surveillance program, they may be able to detect diversions earlier, before patient safety is put at risk. One of the biggest barriers to stopping drug diversion is proper reporting tools implemented and used at the hospital. Prevention measures and proper reporting of drug diversion to authorities are critical to reducing drug diversions and protecting patients.

Ray Vrabel is senior director, medication systems strategy, Omnicell.
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