A data-driven approach to minimizing diversion

As prescription drug abuse in the United States escalates, diversion of controlled substances is becoming an increasingly critical issue for hospitals and health system executives to monitor. In hospitals, diversion of controlled substances not only negatively impacts staff and places liability on the facility but it also affects patient safety, satisfaction, and in most cases, the hospital’s bottom line. As such, hospital executives are looking to pharmacy leaders to provide creative solutions to proactively prevent diversion and better control this evolving public health issue.

For Ohio-based Mercy Medical Center (MMC), the solution started with the implementation of a data-driven approach to prevent narcotic diversion. This approach evolved into a well-honed, collaborative process engaging stakeholders across the hospital to execute a unique combination of strategies around medication dispensing, waste disposal, and reconciliation.

The challenge

Classified as an epidemic of abuse by the Centers for Disease Control and Prevention, prescription drugs are the most common drug choice by nearly one-third of people aged 12 years and older for first-time drug use, according to the National Survey on Drug Use and Health.¹ In Ohio, prescription drug abuse is the cause of alarming rates of unintentional drug poisonings, with associated death rates increasing by 366% from 2000 to 2012.²  

To address the issue of community access to prescription narcotics, Ohio established the Ohio Automated RX Reporting System (OARRS), a statewide system through which pharmacies report daily on their distribution of controlled substances. This system enables pharmacists to look up patient activity associated with controlled substance use across multiple pharmacies statewide-a model being employed increasingly in states across the nation.

Although systems such as OARRS enable better collaboration to curb prescription drug abuse in the community, diversion issues among hospital staff are another growing challenge for the healthcare C-suite to address. Further exacerbating this issue is the broadening scope of diverted medication types. Because schedule II controlled drugs are protected by lock and key, a number of schedule III, IV, and V drugs-such as alprazolam, lorazepam, and pregabalin to name a few-are now being diverted at higher rates due to their greater accessibility.

As is the case for hospitals across the nation, finding the resources to implement an effective drug diversion prevention program was a considerable challenge for the 476-bed MMC. Maintaining a medical staff of 620 members and an employee base of 2500, the organization needed to track a growing number of medications at risk for diversion, as well as monitor activity in traditional high-risk areas such as the operating room (OR) and emergency department and throughout all units in the hospital.

Leveraging a foundation of technology and analytics

With strong backing from the C-suite, the pharmacy department at MMC developed a system of analytics and governance to proactively address narcotics monitoring and reporting. The first line of detection begins with leveraging the narcotic reporting system found within the organization’s automated medication dispensing cabinet solution. A weekly narcotics dispensing report is now run for every unit in the hospital and reconciled with administration records and physician orders. When nurse managers are unable to match records, a need for further investigation is identified and can be done in a timely fashion.

At this level, analysis is turned over to the pharmacy department, where the unreconciled transactions are compared to waste reports as well as peer-to-peer comparisons. All of these reports can be quickly run via that pharmacy department’s decision support applications, providing both the individual and global views needed to make informed determinations regarding these transactions. Additionally, the decision support software provides up to 24 diversion factors, so the pharmacy can ensure actual diverters are identified while ruling out innocent staff members. The ability to view an individual employee’s dispensing pattern and compare it to others enables pharmacists to evaluate the cause behind behavior changes, either as potential diversion or for a legitimate reason, such as increased number of shifts on a different unit with higher patient acuity. Relying on data to drive the investigation process provides objective, comprehensive results that lead to quick resolution of potential diversion issues.

Without the support of automation and reporting tools, the ability to drill down to this level of detail is an incredibly time-consuming process. In the past it could take months, if not years, before an offender would be identified due to the simple fact that resources for such a time-intensive manual task simply were not available. Now MMC can readily identify problems within a matter of hours and support their findings with comprehensive data.

The proactive nature of this governance process has decreased diversion activity-both from early identification of potential issues and deterred diversion from increased staff awareness of the strict monitoring policies. The process also promotes patient safety and improved care by ensuring patients receive their medications as ordered.

Tips for getting started

From a best practice perspective, hospitals and health systems need an analytics and reporting foundation to sustain a proactive diversion prevention system. Also critical is a well-established, collaborative relationship between nurses and pharmacy staff.

Start small by engaging nurse leadership in efforts to review weekly reports of medication transactions. Initial efforts can include random samples demonstrating the importance of reviewing medication orders, charts, and administration reports to track medication without overwhelming nurses with paperwork. If a hospital’s medication distribution model engages automated dispensing cabinets, determine which narcotics dispensing reports exist and orient nurse leaders to the format and data included in reports so they can reconcile against physician orders and administration on a weekly basis.

Although the process is simpler and requires fewer staff resources when data are collected automatically, it is possible to improve diversion prevention strategies with manual systems.  For instance, MMC has established effective processes for monitoring anesthesiology activity in the OR through manual tracking, where anesthesiologists manage their own medication boxes. If medications are wasted, they are sent back to the pharmacy department in a locked box where the pharmacist disposes of them. A refractometer is used to verify that the contents in the box are truly controlled substances, as opposed to a substitute, before disposing of the medication. The box is then returned to the provider after records are manually reconciled. 

It is also critical for all stakeholders, including the C-suite and nursing leadership, to understand the value of timely, objective data in guiding investigations to ensure the best steps are taken for the bigger picture of staff and patient safety.

Putting the right processes and tools in place to support a sustainable program fits best with the pharmacy mission. As the hospital’s watchdog for safe, uncompromised dispensing on units, pharmacy leaders must work to create a safer environment for employees and patients, reduce financial risk, and enhance overall operations.

References

1.    The White House. Office of National Drug Control Policy. Prescription drug abuse. www.whitehouse.gov/ondcp/prescription-drug-abuse. Accessed July 6, 2014.

2.    Healthy Ohio. Ohio Department of Health. Drug overdose in Ohio.  www.healthy.ohio.gov/vipp/drug/dpoison.aspx. Accessed July 6, 2014.

Mr Feucht is the director of pharmacy services at Mercy Medical Center, Canton, OH.