2 realistic scenarios: Drug diversion prevention best practices

Jennifer, a nurse who had worked at Hospital A for less than two years, was taking patient pain tablets (mainly hydrocodone) and replacing them with diphenhydramine tablets (commonly known as the brand name Benadryl), a diverting technique known as “substitution.” She also was frequently stealing medications using the override function of the hospital’s automated drug dispensing machines (ADMs), effectively walking off with medications even before a pharmacist was able to review patient drug orders.

Pharmacy department staff began to suspect diversion when Jennifer appeared on several anomalous usage reports, which were generated periodically as part of the department’s audits. Pharmacy staff routinely identify frequent users and send high-user reports to the applicable nursing departments monthly for them to perform additional audits. Every month, nursing reported back to the pharmacy department that “everything looked fine.” However, Jennifer continued to appear as a high user on the anomalous usage reports. Something wasn’t clicking – and the pharmacy staff decided to dig deeper.

Staff ran several reports, including information about dispensing administrations and discrepancies, for all available drugs during a six-month period. It was particularly enlightening to look at the drugs dispensed and compare that information to patients’ pain scores. Ultimately, Jennifer’s patients' pain scales did not align with the hydrocodone timing and amounts, while additional analysis identified high use of diphenhydramine. The combination of these findings solidified suspicion of drug diversion. An investigation ensued, and, during an interview with the investigation team, Jennifer admitted to diverting. She was placed on probation at the hospital, and the hospital staff connected her with a substance abuse treatment program so she could get well.

Best practices for drug diversion monitoring follow-through

This story about Jennifer highlights the risks to organizations of not following through when potential drug diversion incidences are identified. The pharmacy department flagged this potential diversion multiple times, but the nursing staff (most likely due to overstretched resources and frequent staff turnover) did not follow up on the issue. It wasn’t until the pharmacy department decided to look closer at what was happening that the drug diversion was verified.

To help promote better follow-through after drug diversion monitoring, organizations should make sure their policies and procedures include controls such as the following:

• Define nursing expectations for audits.
  The nurses in this scenario were doing the audits but were just “checking the box” when it came to reporting back to the pharmacy team. Communicate clear expectations about what everyone on the team should be doing regarding audits and reporting suspicious activity. This includes pharmacy oversight of the completed nursing audits for timeliness, accuracy, and completeness.
• Make sure pharmacy conducts audits of overrides.
  Diverters like Jennifer often steal drugs from hospitals’ ADMs by overriding the step when a pharmacist reviews the medication that is to be administered to a patient. Hospitals must document when override audits should occur and the steps for performing them, and pharmacy staff should conduct periodic override audits.
• Give pharmacy oversight of audits.
  When pharmacy staff has oversight of all drug-related audits, their knowledge and expertise can be an asset in helping identify diverters. Pharmacy staff should implement periodic audit checks, making sure the audits are being conducted in a timely manner and that the information required to be documented (for example, pain scores, dispensing information) is included.
• Track and trend outliers.
  A common challenge within a hospital’s drug diversion program is information about potential diversion activity becoming lost or not followed through on, resulting in missed escalation or investigation. Even a simple tracking and trending sheet can help staff keep track of suspected diversions, monitoring and reports, and the outcome of the results (for example, whether an escalation or investigation occurred).
• Document escalation and investigation procedures.
  Escalation and investigation procedures need to be outlined clearly for staff to follow. Procedures should be as specific as possible (for example, “an investigation should occur within the first 24 hours of a potential diversion being flagged on a report”).
• Establish a drug diversion committee.
  This committee should have oversight of the drug diversion monitoring process and meet regularly. It should comprise members from across the organization, including pharmacy, patient care, compliance, risk management, human resources, and executive leadership.
• Use drug diversion software to send reports to nurses for review.
  Such software can allow all parties to share information about potential diversions (for example, pharmacy could send a list of frequent anomalous users or outliers to nursing leadership for review). Organizations should outline within their drug diversion policies and procedures how frequently information should be shared, including the type of feedback and when the feedback is expected.

Mark was a hospital pharmacy employee who, as part of his role, was responsible for purchasing medications from a wholesaler. He also oversaw the intake of those medications at the pharmacy’s receiving area.

In the more than four years Mark worked at Hospital B, he repeatedly would purchase extra drugs, including fentanyl and other opioids. When the drugs arrived at the hospital, he was always there to receive them. He would meet the deliverer at the door and take the package with the drugs and invoice inside to his drug delivery processing area. Mark would make sure his orders to be diverted had only a few drugs on a single invoice, and then he would take those drugs and matching invoices (guaranteeing no paper trail) and place them in his backpack in the corner of his processing area.

As Mark became savvier at diverting drugs, he would order a supply and “transfer” the drugs out of the hospital, going as far as to document that the drugs were taken to another area of the health system, such as a nearby outpatient clinic. Mark completed the appropriate transfer documentation, but no other member of the hospital staff ever followed up to verify the clinic had received the drugs. Anyone who had followed up would have found that Mark was taking the drugs home and selling them to people in nearby communities, exacerbating the substance abuse issues in the hospital’s service area. Unfortunately, Mark’s behavior was discovered only when he did not show up for work one day and was found to have overdosed in his home.

Best practices for purchase-to-stock reconciliation

Mark’s story brings to light a very straightforward – and unfortunately common – diversion method. Some purchase-to-stock reconciliation best practices include:

• Have an independent person perform purchase-to-stock reconciliation.
  Especially in larger organizations, invoices typically are automatically sent to accounts payable to be paid. One of the only ways to catch a purchase-to-stock diversion, therefore, is to have an independent staff member perform the reconciliation – someone who is not allowed to purchase or receive drugs. Reconciliation should be performed at least monthly.
• Have two people handle controlled substances.
  Part of the secret to Mark’s success was that he was working alone. Two people should be put in charge of purchasing and stocking. If that isn’t possible, at least two people should be present to open and inspect each package and record the incoming drug inventory.
• Establish a well-documented process to reconcile wholesaler drug purchase reports with stocking reports.
  The purchase report should come directly from the wholesaler so it cannot be manipulated.
• Have special considerations in place for CSOS controls.
  Organizations that use the U.S. Department of Justice Drug Enforcement Administration (DEA) Controlled Substances Ordering System (CSOS) as a reconciliation control (the CSOS allows for “secure electronic transmission of controlled substance orders without the supporting paper DEA Order Form 222”) should make sure the ADM stocking receipt and invoice are used for CSOS receiving. In addition, the organization should make sure that the person responsible for logging into CSOS and verifying that the incoming drugs were stocked does not have access to purchase or receive the drugs.
• Periodically review who has access to purchase drugs.
  Often, organizations will find that terminated employees still have access to the wholesaler or CSOS.
• Reconcile transfers between the facility and other DEA registrants.
  In the story, Mark created paperwork for fictional transfers between his hospital and a clinic affiliated with the health system. If any hospital is transferring drugs to its clinics or retail locations, that needs to be documented and verified. Had the hospital had a closed-loop system in place for all drug transfers, Mark would not have been able to divert so many drugs and put his and others’ lives at risk.

Reach out for more drug diversion prevention best practices

Effective drug diversion prevention is a continuous undertaking. Organizations need to establish effective policies and processes across this multipronged effort, from monitoring and reporting to investigating and beyond. For assistance with enhancing your organization’s drug diversion prevention efforts, including more best practices to navigate potential drug diversion scenarios like these, consider contacting drug diversion specialists.

*Both stories in this article are fictional, including the named characters.