Establishing an Effective Drug Diversion Plan in Outpatient Surgery

Ramifications for patients when their medication is diverted may include unmitigated pain, risk of infections, and receiving care from an impaired healthcare staff.¹

This widespread health issue is not only seen at the bedside. Abuse of oral and injectable controlled substances spans across clinical areas and all levels of organizations, with Fentanyl being the most commonly diverted drug.²

As difficult as it is to imagine your employees and colleagues participating in this criminal behavior, ambulatory surgery centers (ASCs) are challenged with executing proper monitoring and prevention plans to keep staff and patients safe.

The CMS Condition for Coverage 416.48, Administration of Drugs, requires an ASC’s system to be “capable of readily identifying loss or diversion of all controlled substances in such a manner as to minimize the time frame between the actual losses or diversion to the time of detection and determination of the extent of the loss or diversion.”

Do your policies and procedures minimize drug diversion?

Mary Jo Steiert, BNS, RN, CNAMB, Director of Clinical/Nursing Services at Rose Surgical Center in Denver, spoke with Periop Life about how you can establish and maintain an effective drug diversion plan.

1. Question: CMS states scheduled drugs should be “periodically reviewed.” How should we interpret “periodically?”

Mary Jo: Drug inventory should be reconciled daily by counts or checking for discrepancies with an automated system. Weekly or monthly review of inventory should be performed.

2. Question: If your budget does not support purchasing an automated medication dispensing system, what other processes would you put in place?

Mary Jo: Monthly chart audits should be completed to match what has been ordered, signed out, used, and wasted. Rotate the audits among staff to increase awareness of the importance of documentation and following protocols. Review and compare drug orders with drugs received - and make sure that the same person who orders is not the one who receives. Finally, review usage for higher-than-expected levels.

3. Question: What are some key points to present to the governing board in a business plan to advocate for an automated medication dispensing system?

Mary Jo: Discuss the costs a potential diversion would have on the center – bad publicity could impact business, as well as patients and staff. Depending on the size of the ASC, is it truly cost effective and what other measures can be put in place?

4. Question: What are some ways to engage the entire team, including staff, physicians, and ancillary partners to “see something, say something” when they see suspicious behavior?

Mary Jo: Round with staff and ask what their perceptions are of diversion and how to be aware of some of the signs that may indicate unusual or suspicious behavior. Share examples of situations that have occurred at other facilities and communities.

5. Question: What are other important facts for ASC leaders to consider when implementing a diversion minimization program or reviewing and updating an existing program?

Mary Jo: Implement a Medical Diversion Team that meets regularly to review audits, inventories and concerns. The team should meet regularly and be available if a situation occurs. You can also establish periodic random testing of syringes to validate contents.

References:

1. Nyhus, Julie. "Drug diversion in healthcare: Prevention and detection for nurses." American Nurse Journal, vol. 16, no. 5, May 2021, pp. 24+.
2. “Quick Safety: Drug diversion and impaired health care workers.” The Joint Commission. April 2019. Issue 48.