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Establishing a Controlled Substance Proactive Diversion Program

This presentation discusses the implementation of a proactive diversion program to prevent and control the abuse of controlled substances in healthcare organizations. It covers topics such as the types of diversion, the role of multidisciplinary teams, data analysis, education, and lessons learned.

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Establishing a Controlled Substance Proactive Diversion Program

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  1. Establishing a Controlled Substance Proactive Diversion Program Russell Dorsey, CPhT Special Projects/Indigent Care Program Coordinator Baptist Health Medical Center – Little Rock

  2. Disclosure • I have no financial interests or other disclosures of conflict of interests for this presentation.

  3. Pharmacist Objectives • Outline controlled substance diversion • Summarize a proactive diversion program • Implement proactive diversion procedures

  4. Technician Objectives • Define controlled substance diversion • Outline the organization of a proactive diversion program • Explore the ways to implement proactive diversion procedures

  5. What is diversion and what does it mean to my organization? • Transfer of medication from a lawful to unlawful channel of distribution or use • Patient Safety • Patient/Community Perspective • Liability & Fines

  6. Question? What is the estimated rate of nursing staff with substance use disorder? • 2% • 5% • 10% • 15%

  7. Outline CS Diversion • Drug Theft • Personal Use • Sale • Use by family or friend • Tampering • Doctor Shopping • Illicit practices by health care providers • Forging Prescriptions

  8. Drug Theft – Medical Staff

  9. Drug Theft – Patients/Visitors

  10. Tampering

  11. Doctor Shopping

  12. Illicit practices by health care providers

  13. Summary of Proactive Diversion Program • Collaboration • Data Analysis • Identification • Reporting • Process Improvement • Education

  14. Implement Proactive Diversion Procedures • Multidisciplinary Diversion Response and Prevention Team • Diversion Tip Line • Data Analysis • Samples and Testing • Education

  15. Question? • Which organizations currently have a Multidisciplinary Proactive Diversion Committee that meet on a regular basis?

  16. Multidisciplinary CSDPP • Monitor & audit anomalous/suspicious users • Monitor compliance topics with regard to policy • Standardize review practices • Writing and editing policies and procedures • Develop education & communication

  17. Diversion Tip Line • 24/7 call in line • Anonymous and confidential • Immediate action on reported individual • Reporting user able to obtain updates

  18. Data Analysis • Pharmacy • 222 Forms - Weekly • Separation of duties • Purchase History vs Charge Files – Monthly • Anomalous Users – Monthly • CS Inventories • Pharmacy Information System (PIS) • Unreconciled Dispenses – Daily • “Not Given” CS – Daily • Full of administration history - Monthly • Automated Dispensing System (ADS) • Open Discrepancies -Daily • Closed Discrepancies - Daily • OR Reconciliation - Daily • Pharmacy Compare Reports – Daily • Override Transactions - Daily • Nursing Inventory Compliance – Weekly and Monthly • Removals After Discharge – Weekly • Temporary Patients - Monthly

  19. Samples & Testing • Random employee drug screens • For cause drug screens • Controlled Substance Waste • Pharmacy Compounding Waste

  20. Reporting • Pharmacy • Nursing • Anesthesia • Human Resources • Compliance • Rehabilitation/Drug Courts

  21. Education • Annual CBLs for staff handling CS • Rounding with clinical and administrative staff • Controlled Substance accountability during nurse orientation

  22. Lessons Learned • Understand the intricacies of workflow and staffing • Communicate with front line nursing • Look at your data every way possible & keep an open mind • Keep communication lines open • Establish a baseline for education • Ask Questions

  23. Take-Aways • Perform gap analysis for your facility • Start with the “low hanging fruit” • Open a dialogue across disciplines with feedback

  24. Questions?

  25. Resources • ASHP Guidelines on Preventing Diversion of Controlled Substances, American Journal of Health System Pharmacists 2017; 74:e10-33. • Arkansas Department of Health, Pharmacy Services and Drug Control Branch, Rules and Regulations Pertaining to Controlled Substances, Dec. 1, 2014. • Arkansas Prescription Monitoring Program, FY 2017 Third Quarter Report January – March 2017. • Drug Diversion in Healthcare, The Journal of Global Drug Policy and Practice.

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