Keeping patients safe from harm while reducing liability

Drug diversion presents significant liability risks to an organization from a regulatory, financial and public relations standpoint. Several healthcare facilities have lost lawsuits and payed millions of dollars to patients harmed because of employee drug diversion or problems with documentation or processes.

Case in point: In 2021, a 15-hospital health system in Michigan paid a $7.75 million penalty to settle a federal investigation that revealed that hospital officials were distributing opioids and other drugs without prescriptions. The health system was publicly criticized for having an ineffective system in place, failing to catch these kinds of problems. The incident led the hospital to implement a robust drug diversion prevention program.

A risk to patient & workplace safety

Drug diversion among healthcare workers is substantially underestimated, undetected and underreported. Drug diversion occurs when medication is redirected from its intended destination for personal use, sale or distribution to others. It includes drug theft, use or tampering (adulteration or substitution). While it is not a new issue, many hospitals do not have policies and procedures in place strict enough to effectively prevent it from happening.

Kara Fortune
Kara Fortune, PharmD

“If a patient is underdosed with a pain medication that has been ordered by the provider, it means they may not be getting the pain relief they need,” says Kara Fortune, PharmD, Director of Pharmacy Solutions and Member Support at HealthTrust. “Another risk is exposure to infectious diseases from contaminated needles if used by a healthcare worker. This can be compounded by the healthcare worker’s impaired performance, when they are not of sound mind and unable to effectively care for patients.”

4 steps to creating a medication diversion prevention program

All health systems should have a medication diversion team and develop a coordinated and systematic approach to prevent, detect and report medication diversion.

1. Establish a medication diversion team.

It takes a multidisciplinary medication diversion team, with your CEO/president or other chief officer serving as program champion. Pharmacy and nursing teams should lead the charge, along with human resources, facilities, patient safety, risk management and security as other key team members.

2. Implement a systemwide policy & commit to adherence.

Your controlled substance prevention policy should address key aspects such as access, chain of custody, surveillance/reporting and employee accountability.

“Simply homing in on preventing drug diversion often changes people’s behavior because monitoring is now happening and documentation is being reported,” explains Fortune.

The policy should also dictate the proper storage of controlled substances and other medications that patients bring into the hospital.

3. Create & maintain a surveillance system & employ diligent reporting practices.

The industry offers many technologies around preventing drug diversion, including automated dispensing cabinets with built-in reporting features and software built with artificial intelligence to help facilities determine when something is out of the ordinary. Technology can help identify the frequency with which controlled substances are being accessed, patterns in pain medication distribution and any discrepancy within predetermined guardrails established by the medication diversion team.

“To have a safe work environment, it’s important to have a culture where if anything feels off about a situation, such as a colleague exhibiting abnormal behavior, altered physical appearance and poor performance, employees feel comfortable notifying the supervisor and using the right steps based on policies and procedures to report it,” adds Fortune. Awareness and recognition are the first steps to prevention.

It’s also critical to ensure regulatory compliance. “Many hospitals fail to report diversion to the Drug Enforcement Agency (DEA) on form 106, as required by law (21 CFR §1301.76(b)). Failure to do so not only violates DEA regulations but also violates the Medicare Conditions of Participation (CoPs) for hospitals,” says Fortune. “If diversion is found, a hospital is required to report it to regulatory bodies, which include the DEA, state regulatory boards, pharmacy boards, nursing boards and the Food and Drug Administration.

4. Evaluate progress & develop metrics.

Multi-hospital health systems should share best practices and ensure metrics are aligned, continuously monitored and uniformly reported.

How HealthTrust can help

HealthTrust’s Pharmacy Advisory Solutions team can help your health system or hospital develop a drug diversion prevention program and ensure successful implementation. It starts with creating a multidisciplinary medication diversion team, developing a controlled substance diversion prevention policy/procedure and identifying and/or aligning metrics. The HealthTrust team also provides a robust toolkit that is customized to your health system or facility, to include supporting resources such as a Medication Diversion Team charter, a template for meeting minutes, audit form examples, a DEA guidebook and more.

Learn more about drug diversion and other Pharmacy Solutions from HealthTrust or contact your HealthTrust Account Manager for more information.

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