Minimizing Diversion Risk in Procedural Areas, Operating Rooms, and Emergency Departments

This is the second in a series of articles based on diversion management webinars hosted by Omnicell, and featuring drug diversion expert Kimberly New, JD, BSN, RN, and other speakers.

The Inherent Risk of Procedural Areas

In 2009, one Colorado hospital faced a serious investigation following the outbreak of two cases of hepatitis C in patients who seemed to have no traditional risk factors for the infection. Further investigation showed that an OR technician had been recently dismissed from the hospital in question for tampering with pre-drawn fentanyl syringes left unattended in the operating room. This ultimately led to the recall of 8,000 hospital patients who were potentially exposed to the contaminated syringes, and at least 18 documented hepatitis C transmissions.

The large quantities of powerful drugs and inherently less secure nature of procedural areas, operating rooms, and emergency departments put these areas at high risk for drug diversion. In such areas, non-uniformity of groups, processes, and records make it more challenging to detect diversion, but strategies can be devised to mitigate diversion risk.

Transporting Patients with Medications

When seeking to prevent diversion, carefully consider how controlled medications are secured and accounted for when they accompany patients being transported to another location, such as the CT scan suite. Once a controlled medication has been removed from the drug cabinet, special care should be taken with the transport of that medication—storing it in specialized pre-made transport packs, rather than in a pocket or emesis basin. Once the medication has reached its intended destination and been administered, the packs can then be checked-in by designated staff members to ensure accountability.

Wasting and Handoffs

Disposal of medication waste after procedures is equally important, and facilities should establish who will have responsibility for wasting. Although the immediate disposal of waste after administering may not be feasible in all cases, take care to ensure that medication waste from syringes, drips, and PCAs is not left unattended. Consider selecting random samples to analyze the waste and verify the contents of syringes.

In addition, limiting the amount of times a medication is handed off from one professional to another increases accountability. If handoffs have to occur, both staff members should review the administration record, visually verify what’s being handed off, and then sign off in the medication record.

After-Hours Procedures

After-hours procedures should adhere to the same safety standards as day-time shifts to minimize opportunities for diversion. It’s helpful to round after normal business hours for procedural areas that are open 24/7 to assess whether processes are being followed the same way you would expect during the day.

Because of limited staff availability, after hours procedures can make wasting and witnessing especially challenging. There may be only one person present with access to the drug cabinet. In the cardiac cath lab, for example, there may be an RN who has access to the cabinet and a technologist without access.

Some facilities have a health supervisor witness the waste, while others require a physician involved in the case to witness it. Kim New recommends avoiding situations in which waste is stored in a locked drawer until the next workday, because the waste can be accessed by others during this period.

Record Reconciliation and Discrepancies

A best practice for procedural areas is to reconcile what is removed, what is documented, and what is wasted. If this can’t be done, all staff should be audited on a regular basis to determine if there are patterns indicating potential diversion.

Discrepancies in procedural areas are sometimes overlooked or treated a little more casually than in other areas. Discrepancies need to be identified quickly and resolved. Each discrepancy should be documented and tracked over time to ensure that patterns of discrepancies are identified and addressed.

Effective Auditing Techniques

Effective auditing is an essential part of a proactive diversion program. However, with many procedural areas there is no one-size-fits-all outline for conducting these audits. Kim New suggests a few methods for conducting diversion audits:

  • Group individuals by types of areas or cases for comparison. Certain anesthesia staff may regularly work in specific areas or on specific types of cases. For example, some may work primarily in cardiac cases, and they could be compared to each other.
  • Compare staff using a self-to-self, month-to-month comparison, looking for irregularities in a staff member’s drug activity from their previously established norms.
  • Conduct regular record reconciliation against sample sets of transactions. If time is limited, then focus on drugs that are most commonly diverted.

By conducting effective audits, hospitals can not only detect diversion, but can also create an atmosphere that deters people from trying to divert drugs in the future. In addition, audits bring to light areas to increase security and prevent further cases of diversion.

Physical Security and Badge Access

Physical security is an essential aspect of diversion control in procedural areas and ORs. Access to drug cabinets should be limited, ideally by requiring traceable card readers to get into secured areas.

Camera monitoring is recommended as well, since break-ins do occur in these areas, particularly because drugs are known to be stored there and staff isn’t present 24/7. Generally, any place where controlled medication preparation takes place—including anesthesia work rooms—should have both cameras and good record keeping systems to best control diversion.

Remember that propofol, though not a controlled medication, is at high risk for abuse. As such, make sure this medication is also securely stored.

Proactively monitor badge access, and when reviewing reports, make sure the access time is appropriate. For instance, in an ambulatory surgery center look out for staff entering the area in the middle of the night.

Creating Accountability

When it comes to procedural areas, operating rooms, and the emergency department, Kim New summarizes that “diversion prevention, detection, and response is a multi-disciplinary approach… workflows need to be balanced with security requirements, and—ultimately—processes must provide accountability so that medications can be tracked from the time they enter the facility until they are administered, wasted, or sent back with a reverse distributor.”

Want to Know More?

Visit our previous post on drug diversion here.

Visit for free resources to help take control of drug diversion. The site provides access to upcoming and past webinars on managing drug diversion.

Download our infographic: How Much Harm Can a Single Diverter Cause in Your OR?

Learn about Omnicell solutions for detecting diversion here.






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