I have a crafty nurse to thank for my job as the medication safety officer here at Lehigh Valley Hospital in Allentown, Pa. About 5 years ago, this nurse began stealing the powerful pain med Demerol to feed her own drug habit. She'd punch in her 4-digit code to open the locked narcotics cabinet, cut a few tablets out of the unit dose containers and replace them with other tablets. Because the plastic coverings on the packages were amber, it was hard to see that she was replacing yellow pills with white ones. To conceal her tampering, the nurse taped the Demerol packages together in strips of 10 so, she claimed, they'd be easier to count. She got away with this for 4 months. Eventually, though, somebody noticed that the packages were tampered with and that patients who received bogus pills were still complaining of pain.

I have an automatic drug dispensing system (I'm posing with it in the photo above) to thank for helping me do my job a lot better. Late last year, 4 of our nurses were charged with stealing powerful pain-killers from our drug access machine. We used computer records from the dispensing system to identify the thefts and alert authorities. All 4 nurses have been charged with acquisition of a controlled substance by fraud, forgery, deception or subterfuge, a felony, and possession of a controlled substance, a misdemeanor.

One nurse told investigators that she started by diverting waste Dilaudid, but as her addiction worsened, she began signing out medicine in the names of patients who didn't need it and began to self-inject in a hospital restroom.

Our prescription dispensing system detected the thefts, but not immediately — 1 nurse allegedly had been diverting drugs for nearly 2 years. It's not always easy to detect thefts among the many legitimate drug accesses our nurses make daily. Plus, when someone is diverting a small amount of drugs, it's more difficult to catch. The system is designed to identify patterns. Some are obvious, some aren't.

The lesson here is that people who divert drugs are pretty clever at figuring out ways to get around what you may think are very good drug security policies. Discovering this type of activity requires having strong medication safety and security systems in place. The key is to achieve the appropriate balance of allowing enough access to medications for the proper care of patients in a timely fashion and ensuring proper medication security measures. Technologies to prevent controlled substance diversion fall into 4 categories: purchasing, storage, tracking and monitoring.

Purchasing and prescribing
Electronic ordering. You can electronically order controlled substances (including schedule II substances) in most cases through your wholesaler. The inherent safety feature here is that you can compare reports from the wholesaler to items received to ensure items aren't removed from your system before they arrive. I've heard of scams where staff would order a large supply of drugs on a DEA Form 222, then the order mysteriously disappeared. With an electronic order, you always have a record of what you ordered.

Electronic prescribing. Forging prescriptions is a practice that has been perpetrated by employees and patients when they get access to prescription pads. A computer system with security access and a physician sign-off on prescriptions adds security to this practice, making it more difficult to forge or alter prescriptions because the script goes right to the pharmacy.

Storage
Secure cabinets. Locking cabinets that electronically control access to drugs are becoming increasingly popular. The simplest devices, which record entry to the machine with an individual's password, tell you who was in your cabinet and for how long. A beeping alarm that sounds if the cabinet isn't locked is a nice feature to have, as is a cabinet that offers multiple levels of security (giving staff varying levels of access).

Inventory maintenance. Many devices will keep a perpetual inventory of the contents. You can also consider computerized devices that track the inventory independently of the cabinet.

Biometric identification. The best devices use biometric access (your fingerprint) to allow access to the unit or computer. This prevents someone from stealing a password or the user from forgetting the password.

Tracking
Automated dispensing cabinets. These devices incorporate all the functions described in the storage section and track the medications removed, recording the user, the medication and the patient. They can also record the witnessing of controlled substance waste. Teamed with biometric access, these machines offer a high degree of security. They're able to control access to all the meds. If you suspect drug diversion, you can know who was in the drawer in the last 30 days. These machines record how long you have the drawer open, making it easy to detect tampering.

Monitoring
Surveillance software. These computer software packages analyze data and create reports that suggest patterns of drug diversion. Say, for example, that your automated dispensing cabinet tells you that the average nurse takes out 40% controlled substances and 60% non-controlled. Look for nurses who pull the opposite, as well as for people doing things outside of the range of what's normal.

Waste monitoring technology. Monitoring waste is a good idea anytime an individual has unsupervised, long-term access to controlled substances or when a second individual isn't available to witness waste. Two devices are available to monitor waste: Refractometers, which are inexpensive (around $200) handheld devices you can use to screen that a product is what it's supposed to be, and spectrometers, which are much more expensive than refractometers ($50,000 to $70,000, or some companies offer a pay-as-you-go model), but can't be fooled by an abuser. If you use this device to check controlled drug waste, you'll know what it is.

Tamper-resistant syringes. To access pre-filled medicine cartridges that come in a sleeve, you first must break a paper seal, so it's obvious if these have been tampered with.