Internal audits play a vital role in identifying and preventing diversion, especially in high- risk areas such as pharmacies and procedural areas. This includes inventory management of controlled substances, daily audits of controlled substance data, and concurrent review of medical records. Prescription auditing software is an important tool for examining usage trends and activities by individual staff. Audits should be conducted by two or more individuals so that analyses are not limited to a single perspective and gaps in monitoring resulting from staffing changes can be avoided.20
Hospitals use numerous physical controls to prevent unauthorized access to controlled substances, including storing the drugs in locked cabinets and pharmacy vaults. Security personnel play an important role in monitoring these areas. Hospitals should also require regular counts of controlled substances and documentation when removing them from storage locations.
Automated dispensing cabinets (ADCs) are used in most hospitals to improve patient safety, inventory management and medication security. ADCs are computerized and store and dispense controlled substances near the point of care. They are a useful tool for monitoring and restricting access to controlled substances. ADCs track user access and can provide real-time drug inventory reports.
Security and Monitoring
Hospitals need strong security measures and close monitoring of all employees with access to controlled substances. Controlled substances must be secured, whether in the pharmacy or in procedural areas, operating rooms, or anesthesia work areas. Cameras should be placed in all areas where controlled substances are stored or accessed and at all entry points. Surveillance video should be readily available to investigators and security personnel whenever a diversion incident is suspected.
Education and Training
Hospitals should have education and training programs in place to educate staff on drug addiction and the dangers of substance abuse. Hospital staff need to be made aware of the risk of controlled substance diversion and the resulting threats to patients and the hospital. Staff should receive regular training on all hospital policies and procedures to reduce diversion, including steps they should follow when diversion is suspected.
Healthcare professionals have an ethical duty to protect patients by reporting impaired professionals. An effective training program can help hospital staff to recognize when a colleague may have a drug problem. Signs of addiction may be difficult to detect, but they can include reduced productivity or missed work days, changes in personal appearance, mood swings or irritability, and complaints from patients of ineffective pain medications. Creating a culture of safety and accountability can help make staff feel more comfortable with recognizing the potential warning signs of drug diversion and reporting any behaviors of concern to the proper authority.
The human resources function plays an important role in reducing the risk of drug diversion. Criminal and financial background checks can help a hospital assess the likelihood that a prospective employee may become a drug diverter. Pre-employment screening should include questions about whether the candidate has ever been disciplined or terminated because of drug diversion or other mishandling of controlled substances.21 Regular drug testing of employees with access to prescription drugs, combined with supervisor awareness of warning signs, are also helpful in detecting employees with a drug problem.
(17) U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, What is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs? January 2014.
(18) U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Continuing Progress on the Opioid Epidemic: The Role of the Affordable Care Act, January 11, 2017, https://aspe.hhs.gov/pdf-report/continuing-progress-opioid-epidemic-role-affordable-care-act (accessed December 28, 2017).
(19) Keith Berge, et. al., Diversion of Drugs Within Health Care Facilities, A Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention, Mayo Clin Proc. 2012 Jul; 87(7):674-682.
(20) Gregory Burger and Maureen Burger, Drug Diversion: New Approaches to an Old Problem, Am J Pharm Benefits, 2016; 8(1):30-33.
(21) 21 CFR 1301.90