By Kimberly New, JD, BSN, RN, Diversion Consultant and Educator
This is the seventh in a series of posts about drug diversion.
This continues the previous discussion of the top 10 most common methods diverters use to steal medications. The last post covered diversion methods 1 through 5, and here methods 6 through 10 are described, along with steps to take to detect and prevent each tactic.
6. Cancelled transactions
Diverters usually have an opioid as their drug of choice, but they may also steal non-controlled medications to ease symptoms associated with drug use. They may divert some non-controlled medications to help mask the dilution of an opioid, or to enhance the effect of an opioid. Non-controlled medications are in general access bins and don’t require a count each time medication is removed, making diversion easy to accomplish and difficult to pinpoint.
Cancelled transactions for the same controlled substance may be an indication of diversion by tampering and substitution. For instance, the diverter may access the bin to swap out tampered syringes for intact ones.
How to Detect: Reports that show statistical outliers, user transaction reports, and user watch list reports, if available, are helpful when this activity involves opioids. Staff should know that each time medication is removed, it should be visualized for signs of tampering.
How to Prevent: Doing weekly cabinet checks of all controlled and high risk non-controlled medications can be a deterrent. These should include verifying that expected quantities are present and checking the integrity of the medications.
7. Duplicate doses
This method is most often used by less experienced healthcare providers as a preliminary method of drug diversion. Duplicating doses involves taking a dose for the patient and later diverting a second dose.
How to Detect: This type of diversion is relatively easy to detect through review of statistical outlier reports, user transaction reports, and patient transaction reports. Remember to check activity for all cabinets on a unit, as the diverter may try to cover his/her tracks by removing doses alternately from two or more cabinets.
How to Prevent: While preventing this specific method of diversion is difficult, having a robust diversion prevention, detection, and response program will serve as a deterrent.
8. Removal for discharged patient
This type of diversion occurs most often in units with indistinct departure times, such as emergency departments and ambulatory surgery. In these units, patients may be ready to leave but are awaiting a ride and sometimes require additional pain medication in the interim. Healthcare workers may take advantage of these situations to divert, feeling they can do so undetected.
How to Detect: Review transaction activity regularly, looking for frequent transactions to discharged patients for the same drug. This will also become apparent on statistical outlier reports as the activity escalates.
How to Prevent: Ensure that patient names and identifiers are removed from the drug cabinet system as soon as possible, and ensure that there are checks and balances on CPOE processes so that only authorized individuals are inputting orders.
9. Choosing a noncompliant witness
A diverter who is intent on stealing waste may try to find a witness who will sign off on waste without actually witnessing the waste process. She may choose a newer staff member or a more submissive individual, or may delay wasting until the oncoming shift arrives, knowing the next shift will be distracted and in a hurry to get their shift started.
How to Detect: Statistical outlier reports, user transaction reports, and witness buddy reports.
How to Prevent: Educate staff that they must physically witness waste, and require an incident report when waste cannot be witnessed.
10. Withdrawing medications for patients who don’t need them
Difficult to detect, this method may be an initial stepping stone on the path to other diversion tactics. Over time, the diversion will likely escalate and will become more detectable through healthcare data analytics.
How to Detect: Regular review of user transaction reports and statistical outlier reports. Look for contradictory notes, including nursing notes regarding patient condition, and review medical record entries on pain scores, pain relief, and vital signs.
How to Prevent: Educate staff to review the medication administration history of the prior shift each time they assume care of a patient.
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.
Continuing the Diversion Discussion
The next post on drug diversion will go into more detail on using analytics reports to detect diversion.
View the previous post on diversion here.
Diversion Management Webinars: To learn more about diversion, view our series of Diversion Management webinars hosted by Omnicell and presented by Kimberly New.