All across the country, pharmacy staff are picking up returned controlled substances and placing them back into pharmacy stock. They are removing them from automated dispensing machine return bins and placing them back into the dispensing pockets. Prior to placing the medication back into stock for dispensing, are they checking the item to confirm there has been no tampering? Is the idea of tampering even top of mind for them and do they have any awareness of diversion and its prevalence? When pharmacists are doing an inventory count as part of their unit inspections, are they checking the controlled substances for tampering? If your answer is “no”, or “hmmm I don’t know”, then this is next on your to-do list when it comes to improving your drug diversion prevention and monitoring program.
There was a recent case in Florida where a hospital pharmacist examining fentanyl inventory found a vial missing a tamper-proof cap with a bit of adhesive visible on the top. They also found a second fentanyl syringe which appeared to have had the cap glued back onto the vial. Their observation led to an investigation and a nurse pleading guilty to tampering and theft of fentanyl for personal use. The nurse admitted to removing a portion of the fentanyl from the vial, replacing it with saline and placing the tampered vial back into the automated dispensing machine.
Educate all who have access to the automated dispensing machines on what tampering looks like and the need to be vigilant to the possibility. In the Final Order from the Florida State Board of Nursing, there is no mention of patient harm which is always a real possibility in tampering cases. Perhaps the pharmacist’s attention to detail caught this diversion soon after it started and prevented patient harm.