The opioid epidemic is fueling the growing problem of drug diversion in surgical facilities and attempts to access the controlled substances can happen at any time, no matter how safe your medications might seem or how trustworthy your staff might appear. Follow these steps to ensure your supplies remain in secured locations instead of ending up in the wrong hands.

1Trust, but verify
Always collect sufficient detail about drug transactions. Automated storage and dispensing cabinets are optimal for securing and tracking the use of medications. A locked closet where controlled drugs are "checked out" as needed makes surveillance difficult, but not impossible. If that set-up is in use at your facility, have staff members who pull controlled substances for cases document the date, the time the drug was removed and the time any remaining amount was returned to storage. Auditing drug access and use must be comprehensive and ongoing; ensure accurate and complete amounts for each agent at the start and end of each day to ensure there are no discrepancies.

Some facilities that have manual storage models have nurses pull controlled medications for anesthesia providers. This can facilitate diversion by nursing staff, who may pull more than is necessary and keep the surplus.

I often see facilities put a single staff member in charge of monitoring medication supplies, placing orders and receiving and stocking shipments. Not a wise move. Giving that responsibility to a single staffer eliminates the oversight that's needed to ensure all medications are secure and accounted for. It's best to institute a separation of duties in the drug procurement process in which different staff members are in charge of each step. If your resources aren't big enough to allow for that safeguard, have a staff member witness and sign off on each step of the process performed by the person in charge.

2Secure the sterile field
Close knit staff understandably don't realize that they can't fully trust their colleagues, and so they become complacent about medication security and leave controlled drugs unattended in the OR between cases. The longer drugs remain out of secured storage locations, the more likely they are to be diverted or tampered with.

That's why meds should be prepared as close as possible to administration. But let's not be na??ve about what really goes on during busy days of surgery: Anesthesia providers often pull and draw up medications well before cases begin, place syringes full of controlled substances in unlocked drawers or on anesthesia machines and cover them with a blue towel while they ready the patient or other supplies for surgery. That leaves unsupervised staff members with relatively easy access to controlled substances, so anesthesia providers need a secure space to store prepared medications. Automated anesthesia workstations are ideal, but non-automated cabinets with locking drawers are also effective solutions.

3Don't trust your instincts
Opioids are usually diverted for personal use, although there has been an increase in direct sales of stolen medications by healthcare providers. Diverters steal throughout a shift, stockpile medications and might self-administer the drugs in the bathroom or in their car. Over time, their diverting ways might withhold medications from patients in need and put patients at risk of being infected with bloodborne pathogens.

The staff member who's doing the diverting is almost always a top performer who's very well-liked and respected. In other words, the last person you'd expect. That's why it's important to look for indications of diversion in drug transaction data instead of waiting to notice behavioral red flags, which are a very late sign of trouble. By the time you realize a staff member is diverting, it might be too late to help him or prevent harm to patients.

4Ensure waste is wasted
Visually witnessing the destruction process is required by regulatory and professional standards. Get rid of excess medication as soon as possible after the case's conclusion. Wasting or returning medications should be a 2-person process — the person who's wasting the excess medication and the witness who's watching them do it. Both individuals should document and sign the drug and drug amount that was wasted and the time the wasting occurred.

Don't forget to expel all traces of medications from vials, syringes or IV tubing before discarding them because diverters in the throes of addiction will go to great lengths — including trying to save trace amounts of drugs from thrown-away supplies — to get a quick fix. To eliminate that possibility, consider adding controlled substance waste receptacles to your ORs. The devices deactivate or bind controlled medications to render them unusable. Models specifically designed for the surgical setting are available.

5Go see for yourself
Get out from behind your desk to watch how medications are being handled in actual practice. Pop into ORs to see if drugs are being kept secure or if they're left unattended and can be easily diverted. How are controlled drugs delivered to patient care areas? How soon are drugs prepared in relation to administration? Where is the wasting of excess medication occurring? You won't know for certain unless you perform unannounced rounds. Frontline staff see and know the security loopholes that are impossible for you to notice. Ask them about the challenges they face in keeping drugs secure and how they would divert medications if given the chance. You might be surprised by what you find out, but their insiders' insights will prove invaluable. OSM