Minding Your Medication Safety

Proper medication safety requires surgical leaders to ask some very tough questions. Are employees stealing drugs for consumption or resale? Did a staffer not dilute a drug properly, putting a patient at risk? Are surgeons overprescribing narcotics, or bringing unapproved new drugs into the OR? Let’s look at this complex issue from all the relevant angles.

• Diversion. Unauthorized use or theft of your medications is a primary concern, according to John Karwoski, RPh, MBA, president and founder of JDJ Consulting in Wenonah, N.J. Physically securing all medications — not just narcotics — so they are only accessible by selected doctors and nurses is key to diversion prevention. Locked cabinets are the bare minimum. A more progressive solution, says Mr. Karwoski, is locking drugs in a cabinet or room accessible only by a badge swipe.

Drugs in the OR are another security risk. Mr. Karwoski identifies anesthesia carts left open after surgery as particularly troublesome. “Educate your anesthesia providers to make sure that before they leave the room, they lock their cart,” he says, noting that some newer carts automatically lock when unattended, or with the push of a button. Key-based and combination locks are a burden for time-sensitive procedures, he says.

Make sure the door to a room where medications are stored is never propped open, and that it closes behind an approved staff member, says Mr. Karwoski, who again lauds the concept of badge swiping. “That way you have an audit trail,” he says. “You can get a report from the security company knowing who’s entered the room, or if someone tried their badge and didn’t gain access — a sign someone’s trying to get into the room who shouldn’t.”

Medication security goes beyond locking drugs away, however. “Staff needs to be knowledgeable about potential diversion — knowing how to identify red flags and security risks, reporting to their manager that carts are left open,” says Mr. Karwoski. If someone catches or suspects a staffer is diverting, they have a legal and ethical duty to report it. Administrators must then act carefully. “When you hear about or observe a potential diversion, know what your policy tells you to do,” says Mr. Karwoski. “Immediately jump into action, but document all the steps you’re taking and everything that’s occurring.”

Depending on your location, those steps could include notifying the DEA and state and local agencies, and filing a police report. You should also work with human resources and the management team on the suspected employee’s status and consult your legal counsel.

Another diversion prevention strategy is effective wasting of unused or expired narcotics. Mr. Karwoski says the remainders of partial doses must be wasted non-retrievably, through a chemical or incineration, with a documenting witness. “The person that has the partial syringe needs to show it to a second observer, who needs to acknowledge they’re watching it being wasted, and then they sign off,” he says. Unopened but expired drugs must be transferred to an approved reverse distributor licensed by the DEA.

• Medication errors and unapproved drugs. “Medication safety starts with having a drug formulary that’s been approved by the governing board, and then allowed to be ordered and administered for patients coming in for procedures,” says Mr. Karwoski. “We’ve seen situations where a doctor wants a rep to bring in a drug that has not been screened properly.” The formulary, he says, is your defense in these situations.

“If a patient is harmed, and the lawyer says, ‘Doctor, that drug was never even approved to be used here, how did you get it?’ that facility might as well shutter their doors right away,” he says. “I tell a lot of my centers, ‘Let’s see what the big medical centers do with this drug for six months to a year before we bring it into the surgery center.’”

Meanwhile, approved drugs can be administered improperly, which is another safety issue. “We have drugs that look alike and sound alike,” says Mr. Karwoski, who notes that errors often occur when these drugs are in the same cart. For instance, a blood pressure med and one that prevents nausea have the same color cap. He adds that drugs that require dilution before administration can also be patient safety hazards. He’s heard of limbs being lost and patients coding because drugs weren’t diluted properly. “Every drug is dangerous if it’s not handled correctly,” he says.

• Patients at home. Postoperative prescriptions for same-day surgeries lose safeguards inherently provided by the inpatient model. 

You trust the patient to take the drugs properly and responsibly. Michelle A. Chui, PharmD, PhD, a professor at University of Wisconsin – Madison School of Pharmacy, says counseling and education about post-op scripts should never occur on the day of surgery, when patients and caregivers are stressed and distracted. “They’re not really understanding the risks and issues associated with those medications,” she says.

That’s why it’s vital for outpatient facilities to have trusted relationships with consulting pharmacists. “Pharmacists have probably two years of didactic training just looking at drug profiles, drug-drug interactions and drug-disease interactions, but physicians and nurses have very little didactic training in this area,” she says.

Once the patient is home, diversion is a concern. “Ask questions about the home situation,” says Dr. Chui. “‘Do patients have family members in their home you would worry about, or toddlers who could potentially take meds thinking they’re M&Ms?” Like many, she believes doctors should be stingy about prescribing narcotics, but notes that some don’t want to be disturbed in the middle of the night by a patient in pain who ran out of pills, so they overprescribe.

In many ways, medication safety is more difficult in an outpatient environment than at a hospital, says Dr. Chui. “In a hospital, it’s very easy to control the environment,” she says. “The outpatient realm isn’t a controlled space.” As such, proper precautions and safeguards take on even greater significance. OSM