By Kimberly New, JD, BSN, RN, Diversion Consultant and Educator
This is the sixth in a series of posts about drug diversion.
When auditing for drug diversion, it’s helpful to be aware of some typical methods employed by diverters. In the last post on diversion, How to Spot Drug Diversion in Your Hospital, we listed the top 10 most common methods diverters use to steal medications. Below, we explore methods 1 through 5 and provide suggestions for how to detect and prevent them.
1. Wasting complete doses
With this scheme the diverter will often claim that the patient refused the dose or that there is some other reason the dose could not be administered. It may involve pills or injectables. Wasting a complete dose should be considered an uncommon occurrence and therefore, a warning sign.
How to Detect: On a weekly basis, review reports that show statistical outliers for usage. Dispensing cabinet transaction reports, especially waste transaction reports, can readily identify this type of diversion. Look for transactions involving the same drug, as diverters will usually have a specific drug of choice.
How to Prevent: Educate staff to question wasting of complete doses, have a policy that prohibits removing controlled medications prior to patient need, and require any unused doses to be returned to a designated return bin.
2. Removal under the sign-on of a colleague
Removal under the sign-on of a colleague can occur when there is a stolen password or when a user steps away from the drug cabinet without signing out. This may happen, for instance, when the diverter hovers over a new orientee and sees the sign-on. It may also happen when a worker forgets to log out at the end of a transaction. Even with the use of healthcare data analytics, this method of diversion is often difficult to detect.
How to Detect: Statistical outlier reports and user transaction reports, as well as witness buddy reports.
How to Prevent: Educate staff to keep passwords secure. Ensure that staff members know they should never walk away from the cabinet without logging out, especially during a waste transaction. Set the cabinet timeout to the shortest possible interval.
3. Dropping pills or breaking containers of injectables
This method is evident when there are undocumented doses and when there is frequent wasting of entire doses. The worker will usually become an outlier soon after the start of the scheme.
How to Detect: Statistical outlier reports and user transaction reports will show multiple wasted doses, sometimes with detailed medical record notes about why the dose was wasted. If the staff member claims they frequently drop pills or break containers, check to see if transactions show that this only occurs with a specific drug of choice.
How to Prevent: Require that an incident report be generated any time waste cannot be witnessed.
4. Withdrawing medication without an order
Diverters using this method may have an excessive number of override transactions. The diverter is essentially helping himself to the drugs he wants, and the doses will often be undocumented. If questioned, the diverter may state that he frequently forgets to record verbal orders.
How to Detect: Statistical outlier reports and override reports, particularly if the overrides are always for the same medication. Also, look for medical record entries that are inconsistent with a patient need for the medication.
How to Prevent: Ensure that cabinets are profiled wherever possible, limit the medications that can be removed by override, and require meaningful comments when overrides do occur.
5. Giving a patient less than ordered more frequently
Diverters may use this method to cleverly maximize what is available to divert. For example, if the physician orders 1 mg of morphine every two hours as needed for pain, and morphine is available in a 2 mg syringe, the documentation might indicate that the nurse administered 0.5 mg initially, and 0.5 mg again an hour later. The patient received 1 mg in a two-hour period, but the nurse was able to divert a total of 3 mg of waste versus 2 mg if the medication had been given in one dose as intended.
How to Detect: Statistical outlier reports and user transaction reports. As with other methods of diversion, it’s important to see whether this activity is limited to a particular drug.
How to Prevent: Discourage range orders, and require specificity in orders that are issued. Educate staff to review the medication administration history of the prior shift each time they assume care of a patient.
Continuing the Diversion Discussion
The next article on drug diversion will discuss the remainder of the top ten methods diverters commonly use to steal medications, with tips for detection and prevention.
View the previous post on diversion here.
Kimberly New, JD, BSN, RN
Kim New is a leading national expert on drug diversion. A former compliance specialist at the University of Tennessee Medical Center, New now serves as a consultant on controlled substance security and regulatory compliance to health care facilities across the country. She has served as the President of the Tennessee Chapter of the National Association of Drug Diversion Investigators (NADDI), and as a health care facility liaison to the NADDI Executive Board.
Diversion Management Webinars: To learn more about diversion, view our series of Diversion Management webinars hosted by Omnicell and presented by Kimberly New.