Drug Diversion On Radar of the Joint Commission

Pharmacy Practice News –

Consultants at Joint Commission Resources (JCR) are urging hospitals to double down on efforts to keep controlled substances safe.

This is in light of a Joint Commission finding that 10% of hospitals surveyed in 2019 did not meet medication security standards, including those meant to prevent diversion.

Jeannell Mansur, RPh, PharmD, the principal consultant for medication management and safety at JCR and Joint Commission International, in Oakbrook Terrace, Ill., pointed to a range of medication management and storage gaps that leave controlled substances open to diversion in health systems.

Post-anesthesia care units (PACUs) are particularly vulnerable, Dr. Mansur pointed out. She said fentanyl and other narcotics often are administered intermittently to PACU patients in small doses, which results in nurses reusing the same vial repeatedly for a given patient. Such repeated access poses a diversion danger, she noted during the ASHP 2020 Midyear Clinical Meeting and Exhibition. To lower the risk, “it is important to keep these vials locked up between doses,” Dr. Mansur said, adding that anesthesia carts located in rooms should be under surveillance at all times when the room is not in use and unlocked.

Kim Dove, PharmD, a controlled substance management expert at Omnicell, echoed the need to keep a careful eye on ADCs. Although the advent of ADCs has improved the safety of controlled substance storage on the nursing unit, Dr. Dove noted, there are still vulnerabilities in the transport from pharmacy to the patient floor.

“All medications, whether controlled or non-controlled, are delivered by a pharmacy technician who is responsible for restocking the meds in the ADCs, and these techs often use an open cart for delivery, which creates a potential diversion opportunity,” she explained. “We always joked that if someone wanted to get the narcotics, they just had to watch for the person with the cartful of paper bags!” said Dr. Dove, who was not involved with the ASHP presentation.

Expired Controlled Substances

Another potential point of vulnerability in the medication management process that Dr. Mansur cited is the storage of expired controlled substances in the pharmacy. She said pharmacies should keep expired medications under lock and key until the drugs leave the premises or are destroyed, and also need to develop processes to mitigate the risk for diversion from this stock. For example, Dr. Mansur said, pharmacies can schedule regular counts of expired drugs and investigate any missing inventory, and they can place cameras in the controlled substances area to help review any activities that may have occurred there, in case of possible diversion.

“You need to control these expired medications to the same extent as you would other controlled substances,” Dr. Mansur said. She added that weaknesses in the storage and transfer of controlled substances not only leave the drugs open to diversion, these potential failure points also mean “there is likely no documented chain of custody.”

Dr. Mansur said knowing who has access to a controlled substance at each point in the medication management process—beginning from the receipt of medications in the pharmacy, to the delivery of these drugs to hospital units, their return to the pharmacy and their disposal—is critical to preventing diversion. “A strong chain of custody is a hallmark of a tight medication management system,” Dr. Mansur stressed. To that end, she urged organizations to audit points along the movement of controlled substances to make sure there are no gaps in the chain of custody.

Review Discrepancies

As institutions prepare for their next Joint Commission survey, Dr. Mansur said they should be ready for surveyors to review their policies for managing controlled substances discrepancies. “Take a look at who is allowed to resolve discrepancies when they occur and whether there are red flags that should be addressed,” she said. “For example, if one or more individuals has a large number of discrepancies,” that type of outlier behavior needs to be examined.

Dr. Mansur said creating policies for discrepancy investigation is key, but perhaps more important is ensuring compliance with these policies. If a policy directs resolutions to take place within a specified amount of time, make sure that time line is being met, she said.

Dr. Mansur added that when surveyors find a lax approach to compliance with controlled substances management and storage policies, they may suspect compliance issues with other organizational requirements, and they may review other aspects of controlled substances oversight or management.

Dr. Dove said the best way to achieve compliance with policies for controlled substances management is through the creation of “multidisciplinary diversion committees that review reports, refine processes, handle diversion issues and educate staff. Awareness and accountability are everyone’s responsibility.”

When trying to raise awareness of diversion at your health system, she added, it may help to remind colleagues about the high stakes involved. “Diversion not only hurts the diverter, but can jeopardize the safety of patients, colleagues and the organization.”

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