By JoAnne L. Myhre, CPhT, BA, Drug Diversion Program Manager, Allina Health
This first-hand account of a real diversion incident describes how it was uncovered and addressed by the healthcare institution.
Allina Health, located in Minnesota, is one of the largest not-for-profit healthcare systems. We have 13 hospitals and manage approximately 500 automated dispensing cabinets (ADCs) with over 10,000 users that we monitor on a routine basis. We also monitor the ADCs in our EMS bases.
We have a robust drug diversion program that focuses on strategies for mitigating risk as well as our proactive monitoring work, and we also have developed some standard approaches on how we address a suspected diversion situation—which we call our reactive workflow. Both aspects of our program are highlighted in a drug diversion incident we recently encountered, illustrated below.
Concerns Raised About Out of Place “Float Nurse”
A nurse had floated to a unit that was part of his cohort but was not an area where he typically worked. After this particular weekend shift, the nurse manager of this unit alerted the pharmacy manager to some unusual practice concerns she received from some other RNs working alongside him. They had expressed concern about his pain assessments, not using bedside bar codes during administration, and missing some documentation.
Audit Triggers Initial Investigation
Pharmacy helped conduct an audit. We looked at a month of the unit’s data for controlled substance transactions. We also pulled together the drug diversion core team at that site to start this conversation. We have core teams at all of our facilities, and they consist of the pharmacy manager or director, the nursing lead of the area where the event potentially occurred, HR representation, and other ad hoc members (risk, security, communications, etc.) depending on the issue and event.
This particular RN in question was not due back for another shift for about three days, so it gave the core team time to investigate and look for other issues that may come to light, and decide if any actions needed to be taken. Pharmacy compared controlled substance transactions for this particular person against other nurses in that same unit to see if there were any anomalies.
We noticed a huge number of null transactions, which is a marker for potential diversion, and it was specific to one medication. We also saw some questionable use of the override function with the ADC, and confirmed the missing bedside bar code scans for his group of patients. As we reviewed the transactional data, we also saw ADC transactions on a few other units where the nurse had access but was not assigned to be working at that time.
At that point, the core team decided to place this RN on an administrative leave pending additional investigation. We thought about what we would ask this employee when we met with him. We tried to anticipate the questions he might ask and determine the data that would be presented.
Evidence of Tampering
Meanwhile, pharmacy began to inspect the particular product this nurse had selected during the null transactions on that ADC unit. Some syringes appeared to show signs of tampering. The tamper-evident tape from the manufacturer wasn’t quite lining up like it should be on the metal cap, and the top of the Carpuject containers seemed to be pushed down farther than some of the other ones. It was clear to us as we started looking at those products that we had potential tampering.
We still needed to clarify the situation, so we engaged our security officers and luckily had a video camera above where that ADC is located. The video review confirmed that the nurse was doing some type of manipulation/tampering—removing the medication, doing something with it, and then putting it back in the cabinet. Because of this discovery, we pulled all of our supply of that drug and replaced it to ensure our patients were getting good drugs that hadn’t been tampered with.
Infection Control Concerns
We secured approximately 120 suspicious syringes as evidence and sent a sample of those to be tested for infections. We also pulled in our risk, safety, and quality staff to try to assess any risk to our patients, and we started some deep dives into our data to look for signs of increased foreign infections and look for any patients’ complaints of inadequate pain coverage. Keep in mind this all occurred within the first 36 hours of this issue being raised by the nurse manager.
Federal Agencies Alerted
As our core team continued working on this investigation, we also engaged with our local DEA office. Because of the potential tampering in this particular case, both the DEA and the FDA wanted information prior to our investigation being completed. So we were dealing with the investigation at our site as well as collaboratively working with the federal agencies as the case was still unfolding.
Confronting the Employee
At the end of our investigation, we met with the employee and confronted him with our data and the video footage. He admitted to the diversion and confirmed his tampering process, which was to replace the syringe with saline or sterile water. However, he was adamant that his patients always received the dose that they were intended to receive, and that he used aseptic technique.
During our safety reviews we didn’t find any increase in infection rates and had received no complaints from patients saying that they weren’t getting their medication. All of our tested syringes came back negative for any blood borne pathogens.
The nurse was terminated for diversion and was reported to the Minnesota Board of Nursing. His legal case with the DEA and FDA as well as the board of nursing is still pending.
Incident Prompts New Funding
As a result of this incident, we were able to secure approximately $1 million in funds across our healthcare system to expand our medication storage areas and add video surveillance technology. It was clear to us that the capability to go back and look at video footage of those cabinets the diverter accessed enabled us to quickly hone in and avoid a potentially risky situation for patients.
JoAnne Myhre is a Certified Pharmacy Technician with over 20 years of pharmacy practice experience in various roles. Currently, she is the Drug Diversion Program Manager for Allina Health where she is responsible for coordinating and overseeing the implementation of an effective, risk-based approach for mitigating diversion risks and providing organizational leaders with reliable information on risk exposures throughout the system.
Want to Know More?
View our previous post on diversion here.
To access a podcast of a panel discussion on diversion that includes a talk by JoAnne Myhre and representatives of other healthcare institutions, click here.
Learn about Omnicell solutions for detecting diversion here.