Policies for Preventing and Detecting Diversion in the Pharmacy

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

With the high volume of medications present in pharmacies—including powerful narcotics—combatting drug diversion in this setting must be a priority to ensure the safety of patients and staff alike. Kim New gives some pharmacy-specific suggestions on how to improve existing policies to better combat diversion.

General Prevention Policies for Pharmacies

In the pharmacy, it is important to have policies in place that delineate the separation of duties in procurement, verification of incoming medications, and stocking. Doing so provides an opportunity to better control access to drugs and thus minimize opportunities for diversion. It is important that invoices are carefully examined for what is coming in, what is signed for, and what is received into stock to ensure it is all consistent.

Understanding your facility’s normal stock levels and dispensing timetables enables a benchmark  against which to measure drug activity. Sudden increases in the need for particular medications or supplies—such as narcotics or high-risk, non-controlled medications like propofol—can alert administrators to the possibility of diversion. In addition, preliminary requests for PCA before the drip should have run out can also be caught and flagged for further investigation.

In all cases, whether inside the pharmacy or out in a clinical setting, discrepancies must be handled with diligence when it comes to resolving diversion suspicions.

Automated Dispensing Cabinet Policies

Access to automated dispensing cabinets should be carefully monitored, and immediately discontinued in the event that a staff member is suspended on suspicion of diversion, terminated, or transferred to another role that no longer requires access to controlled medication.  Passwords should be required to be changed at least quarterly.

Provide a limited window of time for other users to access the cabinet by configuring cabinets to have the shortest period of timing out without negatively impacting workflow.

Closing the Loop on Restocking and Returns

You must be able to ensure that what leaves the pharmacy is actually what goes to the floor, and that returns are placed in secure bins, not the general stock.

Preferably stocking and review of returns is done by two staff members. This may not be possible in many institutions, but any areas of concern or areas where frequent discrepancies occur in terms of what is stocked or is in return bins should be identified internally. Ideally, have two staff members involved in reviewing these functions until the issues are resolved.

Transporting Medications

Kim New recommends creating a uniform method of transporting medication to its intended destination, taking into account these precautions:

  • Use locked cabinets or zippered totes in the transport, rather than open containers where medications can be easily accessed.
  • Keep the contents hidden during transport to prevent others from knowing that the materials are from the pharmacy.

Medications from Home

Policies and provisions must be put in place for patient medications that are brought from home. These, too, need a safe and secure place to be stored and must be accounted for in an inventory like any other medication at the hospital.

Physical Security Measures

Kim New advocates that strong physical security measures are the starting point for effective diversion prevention and detection. She suggests the use of strategically placed cameras with footage that is readily accessible by pharmacy directors or other investigators when a diversion case does occur. Specifically, cameras should be placed at:

  • Entry points where anyone comes and goes
  • Any area where controlled medications are stored or accessed
  • Narcotic vaults
  • Areas where drugs are kept when awaiting pickup by reverse distributors

In addition to controlled medications, New also recommends careful monitoring and securing of secondary stock of high-risk drugs like propofol.

Compliance Documentation

To help track and further prevent cases of diversion, it is important to make sure that paperwork is kept up to date and is carefully scrutinized. DEA 106 forms should be filled out and filed with the DEA any time there is an instance of theft or significant loss. Pharmacy employees should be educated on what constitutes significant loss, since it can vary depending on the type of drug.

Regular Audits

Audits remain an integral part of diversion prevention and detection, particularly for high risk areas such as the pharmacy and procedural areas. These audits should be conducted externally—using pharmacy residents, techs, or someone from the internal audit department who is not a member of the pharmacy staff. In addition to general audits, consider conducting focused audits on particularly high-risk items such as PCAs.

Ultimately, New states that, when it comes to preventing and detecting diversion in the pharmacy, “there must be a way to track every controlled medication that comes into the facility to its end use, waste, or reverse distribution.”

Want to Know More?

View our previous post on diversion here.

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

Learn about Omnicell solutions for detecting diversion here.


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