Environment of Care News, August 2015, Volume 18, Issue 8

ECNews

The Joint Commission

August 2015 Volume 18 Issue 8

Environment of Care | Emergency Management | Life Safety

Averting Drug Diversion

How to recognize and prevent medication theft by staff

n 2011, a hepatitis C–infected worker in New Hampshire injected himself with fentanyl-filled syringes he had carefully stolen from presurgical patients and then refilled with saline

to cover his tracks.1 The worker was caught and sentenced to 39 years in prison, but not before 30 people whose blood he had tainted were diagnosed with hepatitis C.1

Far from a rare and isolated incident, this crime underscores the serious repercussions of drug diversion—illegally obtaining or using prescription medications. In the health care setting, drug diversion can have seriously detrimental effects on patients and staff alike. Stolen medications can prevent patients from receiving adequate care and needed pain relief, expose patients to bacterial pathogens and infectious diseases, make patients and colleagues vulnerable to errors caused by an impaired health

care worker, or result in fraudulent records. Health care organi- zations can pay the price via increased liability to civil litigation and regulatory discipline, loss of licensure and participation in Medicare/Medicaid, and bad publicity.

For these and other reasons, it’s important to better under- stand how and why drug diversion happens, identify its warning signs, and develop and implement systems and procedures that can prevent its occurrence.

Good workers, bad choices

Stolen medications are typically used to satisfy an addiction of the thieving health care worker or a colleague or are sold to a third party for financial benefit.2 In fact, a recent USA Today investigation revealed that most diversions by clinicians and

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Controlled drugs can be pilfered for illegal purposes.

Inside

Top News
Joint Commission and ASHE Launch Portal to Address Environmental Challenges

Resources focus on most challenging standards for hospital compliance

6 Clarifications and Expectations: How to Plan for Emergency Utility System Disruptions EC.02.05.01, EPs 8–13 and 16

8 OSHA & Worker Safety: Guidelines for

Zero Tolerance

New OSHA publication helps prevent violence in the health care setting

Averting Drug Diversion

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health care workers are done on a large scale for monetary gain, commonly employing prescription scams; practi- tioners diverting medications for per- sonal use accounted for merely 15% of the 200 cases investigated.3

Theft tactics include opening vials, tampering with syringes or vials that leads to the patient receiving diluted or substituted dosages, draining medica- tions from a vial or syringe after only a portion of the substance is administered to the patient, and collecting discarded ampules or syringes from sharps safety receptacles.2 The pharmaceuticals

most often stolen include opioids like hydrocodone and oxycodone, anti- retroviral drugs, performance-enhancing drugs, and nonopioid psychotropics.2 Most often, nurses, physicians, and other clinical staff are the perpetrators, as they have the easiest access to drugs dispensed within the facility. Ancillary staff are not immune, however.

Because drug diversion is a covert activity that is difficult to observe or track, it is usually undetected and unreported; therefore, no reliable data on its incidence have been published. The US Substance Abuse and Mental Health Services Administration reported that the overall rate of past-month illicit drug use among full-time health care and social assistance workers aged 18 to 64 was 5.5% between 2008 and 20124; a good portion of these workers could potentially have been involved in divert- ing medications.

“Instances of drug diversion have always existed in hospitals and probably always will,” says Bonnie S. Michelman, director of police, security, and outside services, Massachusetts General Hospital, and security consultant for its parent organization, Partners HealthCare, Boston. “The good news is that, thanks to improved surveillance systems, auto- mated dispensing systems, staff education and awareness initiatives, audit pro-

Standards to Stem the Stealing

Joint Commission Environment of Care Standard EC.02.01.01, “The organization manages safety and security risks,” applies to drug diversion prevention and control. Elements of performance (EPs) that apply are as follows:

EP 1: The organization identifies safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the organization’s facilities.

EP 3: The organization takes action to minimize or eliminate identified safety and

security risks in the physical environment.

EP 8: The organization controls access to and from areas it identifies as security

sensitive.

Joint Commission Medication Management standards and EPs that apply to drug diversion control and prevention include the following:

MM.01.01.03: The organization safely manages high-alert and hazardous medications.

MM.03.01.01, EP 3: The organization stores all medications and biologicals, including controlled (scheduled) medications, in a secured area to prevent diversion, and locked when necessary, in accordance with law and regulation.

MM.05.01.11, EP 2: The organization dispenses medications and maintains records in accordance with law and regulation, licensure, and professional standards of practice.

MM.05.01.19: The organization safely manages returned medications. EP 2: When the organization accepts unused, expired, or returned medications, it has a process for returning medications to the pharmacy’s control that includes procedures for preventing diversion.

MM.08.01.01: The organization evaluates the effectiveness of its medication management system.

Efforts to Prevent Drug Theft

Health care organizations need to establish processes to prevent and respond to drug diversion. The Maryland Department of Health and Mental Hygiene5 recommends that these efforts include the following:

Forming drug diversion and response teams at each facility
Developing a standard definition of “significant loss” of controlled substances, with
a special focus on injectable narcotics
Empowering staff to report suspected diversion, including education about applicable legal protections and immunities
Placing electronic medication dispensing systems or other medication storage units in procedure areas
Limiting the ability to declare “drug wasting” to only those staff licensed to handle
controlled dangerous substances
Implementing injectable narcotics count “time outs” after procedures, in order to
tally the amount dispensed and wasted before staff leave the procedure area
Instituting a “stop work” or “lockdown” if there is any missing narcotic post-
procedure
Implementing mandatory staff testing for the presence of narcotics immediately following a discrepancy occurrence
Posting an internal and external hotline for anonymous reporting of suspected drug diversion
Developing a system to safely identify, refer for treatment, and assist employees with substance use disorders

cesses, and more sophisticated reporting mechanisms, it’s more difficult to divert drugs in hospitals today,” she says. “But even one incident puts an organization at risk and can create a challenging vulner- ability. It’s a security issue, a medication management issue, and a safety issue.”

Risky areas and red flags Drug diversion most commonly occurs in areas where medications are stored,

dispensed, and administered to patients. Hence, the most susceptible spaces are pharmacies (especially near an automated dispensing system [ADS]), anesthesia department areas, and patient care units and private patient rooms.

Organizations will want to consider this information as they perform risk assessments for security-sensitive areas, per Joint Commission Environment of Care (EC) Standard EC.02.01.01, EP 8 (see “Standards to Stem the Stealing,” page 4). Having identified an area as

security sensitive, they will need to con- trol access to and from the space.

Drug diversion warning signs to watch for, according to the American Bar Association,6 include a caregiver who does the following:

Demonstrates inconsistent or incorrect charting
Offers to medicate other nurses’ patients on a regular basis
Displays inconsistent work quality, with times of high and low efficiency
Obtains a larger dose of narcotics when an order dose is unavailable and then “documents” the remaining amount as wasted
Requests to care for specific patients
Has patients who show consistent pain scale patterns and/or complain that narcotics are not having the desired effect
Reports frequent ADS stock outages

Just say no

A health care organization should priori- tize creating a program that includes the necessary processes, tools, and protocols

to identify and curb diversion of con- trolled substances. When devising such a program, Michelman says organizations should emphasize seven key components (for additional tips, see “Efforts to Pre- vent Drug Theft,” page 4):

Effective surveillance methodology,
which involves the following:
–Installing the right ADS in the right area
–Requiring identification badges and stricter authentication methods to access drug dispensing systems
–Auditing drug transaction data and inventory via data analytics systems/software
–Installing more and better surveillance cameras
Improved security and monitoring measures. This can include enhancing the pharmacy with bulletproof glass, alarm capabilities, and strong access controls; increasing the human mon- itoring of surveillance screens; and requiring the presence of coworker witnesses who can watch caregivers transport and administer drugs to patients.
Buy-in and involvement with key decision-makers and departments. Proper protocols, thorough reporting, and good auditing and review proce- dures should be in place and should involve at least the clinical care, phar- macy, anesthesiology, security, and human resources departments.
At Massachusetts General Hospital, for example, “pharmacy and nursing staff review relevant reports daily,
and we have a strong drug diversion multidisciplinary task force that meets weekly,” Michelman says.
Nonclinical staff in the care environment, such as facility person- nel, should also be educated in these efforts. Michelman notes that these personnel are sometimes the first to observe or uncover a diversion activity.
For example, they might find drugs or drug paraphernalia secretly stored
behind ceiling tiles or in utility closets.
Enhanced screening of staff, including thorough background screenings of prospective employees and increased random drug testing before and after hire. The US Drug Enforcement Administration (DEA) requires hospitals and clinics that are registered with the DEA to properly screen prospective employees to weed out candidates at increased risk of diverting drugs.
Proper staff training and education that stresses the drug diversion surveil- lance/security measures and policies an organization has in place, warning signs to watch for, the dangers of sub- stance abuse and its impact on patient safety, and the need for prompt reporting of any violations.
Implementation of effective procedures to prevent, detect, and properly report diversion, including policies that align with Joint Commission standards and a zero-tolerance policy for offenders.
Michelman recommends that known drug diverters and their accomplices should be immediately removed from the workplace, with disposition to
be determined—which sometimes includes rehabilitation and return to work.
Reporting of incidents to the proper authorities. Health care organizations should report incidents according to the laws and regulations of their locale. In addition, the DEA mandates the reporting of the theft or significant loss of any controlled substances (21 CFR § 1301.76[b],

§ 1301.74[c]).

The DEA also mandates that organizations take necessary corrective action when diversion occurs and immediately notify the DEA within one business day of a theft or signifi- cant loss of controlled substances.7

“Hospitals should never assume that nothing’s happening. This has to be a focus for hospitals at all times,

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Averting Drug Diversion

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with the goal of constantly monitor- ing and improving,” says Michelman. “We should never take our eye off the problem because people are always going to find new diversion methods, and we need to make sure we are incredibly and collectively proactive in our efforts.” EC

References

Navarro L. Ex-hospital worker gets 39 years for causing hepatitis C outbreak. CNN.com, Dec 3, 2013. Accessed May 20, 2015. http:// www.cnn.com/2013/12/02/health/new
-hampshire-hospital-worker-hepatitis-c/
Berge KH, Dillon KR, Sikkink KM, et al. Diversion of drugs within health care facilities, a multiple-victim crime: Patterns of diver- sion, scope, consequences, detection, and prevention. Mayo Clin Proc. 2012 Jul; 87(7): 674–682. Accessed May 19, 2015. www.ncbi
.nlm.nih.gov/pmc/articles/PMC3538481
Eisler P. Doctors, medical staff on drugs put patients at risk. USA Today, Apr 17, 2014. Accessed May 19, 2015. http://www.usatoday
.com/story/news/nation/2014/04/15/doctors
-addicted-drugs-health-care-diversion/7588401/
US Substance Abuse and Mental Health Ser- vices Administration. Substance use and sub- stance use disorder by industry. The CBHSQ Report, Apr 16, 2015. Accessed May 19, 2015. http://www.samhsa.gov/data/sites/default/files
/report_1959/ShortReport-1959.html
Maryland Department of Health and Mental Hygiene. Public Health Vulnerability Review: Drug Diversion, Infection Risk, and David Kwiatkowski’s Employment as a Healthcare Worker in Maryland. Baltimore: Maryland Department of Health and Mental Hygiene; 2013. Accessed May 19, 2015. http://www
.dhmh.maryland.gov/pdf/Public%20Health
%20Vulnerability%20Review.pdf
American Bar Association. Dealing with Drug Diversion in the Healthcare Workplace: A Primer. PowerPoint presentation from a webinar hosted in Chicago, Apr 29, 2015.
US Department of Justice, Drug Enforcement Administration. Theft or loss of controlled substances—DEA Form 106. Accessed May 19, 2015. http://www.deadiversion.usdoj

.gov/21cfr_reports/theft