July 102016Provider Drug Diversion - Methodologies to Prevent Drug Diversion Pitfalls

- By Tim Olmstead, Managing Partner

You've read the articles and guidelines from the CDC around opioid prescribing. You've studied federal and state requirements for risk mitigation and drilled your pharmacy team on ensuring that controls are in place. You've worked with HR to appropriately engage background checks and you've even followed the "best practice" manual and placed surveillance cameras in key locations and installed highly securitized ADM's for "at risk" drugs. Despite all this, might there still be a way that drug diversion is occurring at your organization? Drug Diversion in hospital and clinic settings is an age-old risk; but as we learn time and time again, where there is a will, there is always a way!

As is the recent case in Muncie, Indiana, in which an anesthesiologist at IU Health Ball Memorial Hospital stole and ingested drugs while on duty, and this past winter at Emory Midtown (Atlanta, GA), the scene of a 5-year, estimated value of 20 million dollars in drugs stolen, theft ring, drug diversion can come in many shapes and forms. And it can happen to anyone!

Drug diversion is a multidisciplinary issue, particularly involving pharmacy, nursing, security, HR, physicians, and clinical support staff. With so many moving pieces, diversion issues can arise undetected for a period of years or longer-if ever. Pharmacy fraud and drug diversion are a growing problem in the United States and even the most reputable hospitals are not immune to this problem despite putting significant thought and time into current inventory controls that meet the requirements of federal, state and local regulations, while also maintaining focus on keeping patients and employees safe.

While there is always room for improvement as it relates to preventing drug diversion, healthcare providers must never let their guard down and lose sight of the interdepartmental coordination and ongoing communication necessary to ensure that drug diversion risk is averted. While certain aspects of drug diversion are difficult to contain, such as the occasional employee impairment issues, reducing both small and large variances in drug dispensations, as in the case of Emory Midtown or the University of Miami Medical Systems (Hyperlink to story), any level of drug diversion can manifest into something far more catastrophic than initially thought. And most of all, patient safety and integrity must be achieved at all times. It's not just the provider liability aspect, it's the right thing to do to ensure patients are safe.

Key aspects many times overlooked in administering an effective drug diversion program are outlined below.

  • Staffing and Resource Allocation:

    An area of drug diversion that organization often overlook is the separation of duties for buying and receiving. In the case of pharmacies serving various physician clinics, floor stock, and other areas, close attention should be paid to the staff ordering and receiving drugs to ensure that these duties are segregated appropriately and proper security and drug counting is engaged consistently. Countless opportunities exist, especially in loosely controlled physician offices where multiple folks have access to drug cabinets and drug samples, that open up a provider to risk for drug diversion. Ensure proper controls are in place and division of duties are properly constructed to prevent "gaming" they process.

  • Falling Asleep at the Wheel:

    It's hard to deny, with the recent focus by the Obama administration on opioid abuse and various high profile drug diversion cases around the country, that drug diversion is not at the forefront of every healthcare organization's risk mitigation dashboard today. But will it be tomorrow? In a hospital or pharmacy setting, where staff work together closely and earn each other's confidence quickly (as there is no other choice) in very critical day-to-day life and death situations, it is not unusual for staff to become comfortable over time when drug diversion goes undetected. With the changing medical record and hospital billing systems, acquisition of new clinics and clinical offerings, healthcare administrators must rely on checks and balances to be carried out on a consistent basis to ensure proper handling of high dollar and controlled drugs. A culture of awareness and skepticism, while it sounds extreme, should always be engaged.

  • Dependency on Technology and Automation:

    People are smart. Smart people work on both sides of the equation: drug diversion monitoring and "gaming" the processes and controls that are in place. At the forefront of any drug diversion program, program administrators should always factor in the human element vs depending solely on security and other technology reporting tools. Often times, drug order to inventory to usage reconciliation analytics carried out by analysts is the only way to truly identify trends or anomalies in drug usage patterns. While software programs can report on statistical elements that may deviate from an established baseline, engaging an analyst and pharmacy matter expert is the strongest way to accurately identify if there is an issue. Every organization is different with multifactorial nuances. No one knows your organization better than your people. Use them!

In addition to the above mentioned areas of focus, which are just a small sample as we could speak to countless elements that play into effectively implementing an effective drug diversion program, hospitals and providers should proactively engage a third party risk assessment of their current drug diversion program to identify gaps or risks in their current practices before serious diversion issues arise. Ongoing monitoring and internal reviews are critical, but also subject to bias, resource limitations, and procrastination. The use of an outside perspective to review your controlled drug and diversion control processes is the best way to protect your organization and your patients from harm.