NV: Drug-Diversion Program Cut Controlled-Substance Discrepancies at Mount Sinai

A daily audit of EHR and dispensing machines revealed documentation mistakes, other errors

After a pharmacy team introduced a diversion-detection program with daily audits for controlled substances, discrepancies between the electronic health record (EHR) and the automated dispensing cabinet (ADC) decreased, a retrospective descriptive study found.

The proportion of discrepancies per month went from 33% of controlled substance transactions to 13% over the course of about 4 months during February to June of this year, reported Kayria Ahmad, MPH, of Mount Sinai Beth Israel in New York City, in a poster presentation at the Midyear American Society of Health-System Pharmacists meeting.

“I was just really surprised that there wasn’t a consistent daily tracking procedure before this, because it is really important,” said Ahmad. “These are controlled substances, and especially in today’s world, we know it’s really important to really crack down.”

The study also described reasons providers gave for discrepancies, which were fairly evenly divided between:

  • Incorrect documentation on Epic: 26.7%
  • Not having disposed of a drug correctly: 24.4%
  • Forgetting to chart medication as administered on Epic: 22.2%
  • Provider ADC errors: 22.2%

The remaining discrepancy justifications were miscommunications between providers when documenting administration (2.2%), and returning waste (disposing of drugs) at a different ADC from where the drug was originally dispensed (2.2%). Extra drugs are normally disposed of in a separate procedure but at the same ADC where they were dispensed.

Researchers conducted a daily review of the EHR system, Epic, for controlled substances dispensed, including fentanyl, midazolam, and ketamine, among others. They also reviewed the ADC server, in this case, Pyxis machines. Where the two reports didn’t match, they sent emails to the provider and the chair of the provider’s department “to provide justification.”

If providers didn’t respond with a justification within 72 hours, their access to Pyxis machines was suspended, and the discrepancy was escalated to the hospital’s diversion committee.

Because the program introduced new consequences for providers, like suspended access to the ADC or escalation to the hospital’s diversion committee, “I guess some people were getting scared in the beginning. So they took it really seriously,” said Ahmad.

But she added that if the justification or reason for the discrepancy was “feasible,” then the provider would not have their access suspended.

The subtext of such programs, Ahmad acknowledged, are ongoing challenges with drug diversion related to addiction, or the fact that some discrepancies just can’t be explained away with a reasonable excuse.

According to the Institute for Safe Medication Practices, substance misuse and addiction among nurses may be as high as 20%. Drug diversion puts patient safety at risk, and costs the healthcare industry billions per year.

Highly-publicized incidents, like at Cheshire Medical Center in New Hampshire, where a nurse allegedly removed almost 8 gallons’ worth of fentanyl solution over the course of 5 months, have thrown the problem into even higher relief.

“If they do repeated behaviors, that’s something to kind of look at,” said Ahmad. “[This is about] promoting accountability of different departments, interdisciplinary collaboration, so that’s another thing that we found was really beneficial.”

Ahmad said that the team also looked for instances of repeat discrepancies from the same provider, which would inform their decisions on consequences for providers. She said they did identify one such provider.

“The good thing about such studies is that she [Ahmad] knew what to do later. Like ‘We found the problem, so what’s our plan?'” Lina Wahba, MSc, a clinical pharmacist at Tawam Hospital in Al Ain, United Arab Emirates, told MedPage Today. She added that, as someone with a clinical background, it was good to see an aspect of operations. “[Ahmad] mentioned that they need to do this — the check-up between the healthcare records and Pyxis work — frequently.”

Overall, there were 1,179 controlled substance transactions over the study period and 45 total discrepancies found from February 19 to June 17. Ahmad, along with the associate director of the department of pharmacy at Mount Sinai Beth Israel, and the pharmacy manager would evaluate the justifications and make decisions on account suspension or escalation. Ahmad and the associate director checked for the daily discrepancies during the study period, and then trained the staff, who now conduct the daily audit.

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Tags: Opioid Crisis

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