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9 Steps to Creating a Drug Diversion Monitoring Program

A nurse gets into a car accident and requires surgery. After surgery, the nurse is prescribed painkillers and becomes addicted. Because she works in a hospital, the nurse has access to drugs and continues to pilfer them to feed her addiction.
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Chart of drug diversion monitoring steps.

This scenario is all too common. Indeed, up to 15 percent of healthcare workers are addicted to drugs compared to 8 percent of the general population. “When you are working in a healthcare facility every day, you have access to medications. It’s easy to become addicted. It only takes a dose or two,” said Kara Earle, the Drug Diversion Specialist at FairWarning, during Steps to a Full-Lifecycle Drug Diversion Monitoring Program, an educational session delivered during HIMSS19 in Orlando.

As a result, hospitals need to monitor – and eradicate – drug diversion, which occurs anytime a prescription drug is removed from its intended path as it moves from the manufacturer to the patient.

An understanding of drug diversion can help. It’s important to realize that in most cases, healthcare workers divert drugs for personal use, not financial gain; that anybody working within a healthcare organization – not just clinicians – can divert drugs; and that controlled substances are the most commonly diverted drugs.

Fentanyl is one of these drugs, but it “is not the same fentanyl you see on the street. It is primarily injectables,” said Police Cmdr. John Burke, President of Pharmaceutical Diversion Education Inc. As such, infection risks are introduced into healthcare facilities. “If a diverter uses a needle and puts it back in the dispensing cabinet or on the anesthesia trays to be used on a patient, that's obviously not sterile,” Earle said.

All told, drug diversion can harm patients as they are denied needed medications and pain relief; it can hinder provider organizations as drug-impaired staff members are apt to make poor clinical decisions; and it can harm the diverters themselves as they struggle with job loss, a criminal record, and turmoil in their personal lives.

As such, healthcare organizations need “to proactively monitor for drug diversion,” Earle said. To accomplish this, hospitals should take the following nine steps to create a drug diversion monitoring program:

Step 1: Capture executive level support. The challenge, sometimes, is getting executives to believe that drug diversion is a problem for their organizations. Burke, for example, once worked with a children’s hospital where leaders didn’t believe that their “compassionate” staff members could have drug problems. But drug diversion is more closely tied to “addiction; it’s not about compassion. If you know people who are addicted, you know that they will go to all lengths to get drugs,” he said.

Step 2: Formulate a drug diversion committee that consists of members from across the organization, including legal, nursing, pharmacy, physicians, security, compliance, law enforcement, and others. This committee should meet regularly to discuss diversion incidents or to conduct diversion drills and educational sessions.

Step 3: Train staff to identify addicts. Some leaders resist such training because they think they will be showing staff how to “go ahead and start diverting medications,” Burke said. However, that’s not how it works, as the “people who are going to divert already know how to divert medication.”

What’s important is that others in the hospital recognize common red flags. For example, diverters often want to work with PRN patients, who are given pain medication “as needed.” When working with these patients, diverters “can either say the patient asked for pain meds, but didn't, and then take the meds themselves, or they can ‘split a shot,’ which means they give the patient half and themselves half,” Burke said.

Step 4: Create the ability to report anonymously. Healthcare workers are more likely to report drug diversion if they will not be identified as the person who “snitched” on co-workers.

In addition, workers sometimes won’t report because they don’t want to get their fellow employees “locked up, or have the SWAT team come in with their masks on and blow down the doors,” Burke said. Workers need to understand that diverters typically are not treated in a punitive manner but instead are offered rehabilitation.

Step 5: Hire and empower a drug diversion specialist who can head the drug diversion committee and oversee the drug diversion management program. Pharmacists, pharmacy techs and nurses are well-suited to this role because they have knowledge of how controlled substances are distributed.

Step 6: Monitor with behavioral analytics and artificial intelligence. A centralized database makes it possible to “track all the clues” that could lead to the discovery of a drug diverter.

Analytical tools can be used to quickly uncover data patterns. Without such tools in place, organizations might only review data monthly. As such, a hospital might get “a 3,000-page report and then have somebody with an Excel spreadsheet trying to reconcile that back to the EHR and calculate standard deviations,” Earle said. “This manual process is very time consuming.”

To address this challenge, FairWarning has developed a machine learning model based on known drug diversion cases at customers’ facilities. By running this model over the behavior of users in EHRs, clinical applications, and dispensing systems, healthcare organizations can detect and remediate drug diversion.

With such systems in place, organizations can daily “look through all of the data that's available and flag different people,” Earle said. “This is changing the way diversion incidents are handled within hospitals because you're not waiting six to eight weeks.” Organizations can identify diverters in 30 days or less — instead of six months after they started to take drugs. As such, these organizations won’t “get to the point where you're finding someone overdosed in a bathroom.”

Step 7: Report to the Drug Enforcement Administration and law enforcement. Organizational leaders must report drug diversion incidents to authorities. “If not, nurses will literally just move from facility to facility and continue doing it,” Earle said.

Step 8: Offer rehabilitation resources to help diverters/addicts recover and get back to work. It’s important to “look at it as a disease,” Earle said. “They're not doing it because they want to; they're doing it because they literally need that drug to function. So, you want to make sure that you have those resources set up for your employees.”

Step 9: Continually improve drug diversion efforts. Leaders should assess the program and identify what needs improvement. Such efforts are “especially important for your executive leadership,” Earle said. “It wants to see that what you're doing is working. So, it's really important to constantly be going back and learn what you can from each diversion incident.”

By taking these steps, healthcare organizations can create drug diversion monitoring programs that can identify diverters and remediate before the diverters can significantly harm their provider organizations, patients and themselves.