Why is Drug Diversion a Patient Safety Issue?

Guest: Michael Van Ornum RPh, RN, BCPS, CPPS

Med Safety Clinical Pharmacist

Join us in a discussion surrounding the intersection of patient safety and drug diversion. Michael is the host of Applied Medication Safety podcast and he asks some good questions. We talk about the common methods of diversion and their impact on the patients. We’ll dive deeper into the ramification of diversion on peers and why they should report concerns. We also talk about some essential components to a diversion program.


Terri: Mitigating diversion makes things safer, and anytime one considers changing a process involving controlled substances for medication safety reasons, we must keep in mind whether those changes will strengthen or weaken our diversion mitigation. And with that, I want to welcome Michael. I’m really looking forward to our discussion today. 

Michael: Thank you, Terri. I’m really excited for this as well. 

Terri: Me too. 

Michael: You have a wealth of knowledge in this space and I think putting the two together, looking at this, coming at it from the safety perspective because right now the podcast that I’m working on is focused on opiate safety and that will touch on questions of diversion, but it’s not always clear where that safety risk is. And then you’re coming from the other side and there are clearly risks on your side and it feels like the patient’s actually caught in the middle because you have your regulatory risk, you have your risks to healthcare practitioners and the work that they do. And really we want to try to drill down to the middle where the patient is and really begin to flesh out where some of those risks are manifesting. 

Terri: Yes, I totally agree. 

Michael: So I guess what I’d like to kind of explore are some of the common diversion pathways that you’ve seen and then we can spool that back to what that looks like to the patient and to the other people caring for that patient. 

Terri: Sure, okay. Yeah, I think there are some common pathways and some are more of a patient safety risk, shall we say. They’re all bad, none of them should be done, but some are more egregious, for lack of a better term. When it comes to patient safety. We see diversion in the sense of patients have PRN orders as needed, that they’ve got them on their profile, maybe they’re never going to need them. Really, it’s just part of the standard orders and so that gives the nurse access to that and they take advantage of it. The patient doesn’t need it, but I’m going to say that they do. I’m going to remove it, I’m going to take it for myself, chart it as given, and it’s for the patient. No harm, no foul, right? Because they didn’t need it. They didn’t withhold anything. Then there’s the other piece where the patient did need it. But the healthcare provider either takes a little off the top for themselves or withholds it and substitutes it with something else that can mimic it to some extent. Either a little bit of pain relief or a change in blood pressure or what have you to make it look like the patient is getting something and they’re not. And so that is clearly a patient safety risk. And then we get to the extremely potentially harmful and that is the substitution by way of injectables. When I said earlier substitution, I meant orals or substituting it with another med clean, a clean med. But the substitution in terms of saline or dirty water or what have you in a vial and then placing that in a position where the patient is going to receive that. So you’ve got your possible needle contamination and then you’ve got your substances being given to them. That is not sterile and certainly not what they’re supposed to get. So we see all of that. But another area that is extremely big and is a large risk is the waste. And I think oftentimes the healthcare professional can justify, well, it’s just trash and it’s not really monitored well. And so let me just take the waste. And so that’s another example of probably not affecting the patient. Unless, of course, the bedside nurse or physician is not giving the patient everything that they should get just so that they end up with waste. So those are some of the common things that we see. 

Michael: All right, so what I heard was the false documenting saying that you gave something but didn’t. It goes in your pocket, the substitution, both for the oral and the injectable. So you think you’re going to be getting opiate medication if you’re the patient, but actually you’re getting something that’s different. So it could be as benign as sterile saline or it could be as harmful as a contaminated product. Instead of oxycodone, you could be getting a tylenol or acetaminophen, right? And then there’s waste, where the waste pathway comes. And I think when we begin thinking about patient safety, we are very familiar with the direct effects of that, where in the first scenario with a PRN medication, it feels like there’s no harm because the patient didn’t ask for it, the patient didn’t get it. So where’s the patient safety in that? But I feel like there’s a secondary risk because if I’m the nurse coming on and I see this patient’s been getting their Prn meds every 2 hours on the hour, then I’m expecting to give this patient pain medication. And it’s not going to take much for me to trigger that because I can see in the medical documentation this history of medication. And if that patient is incapacitated, if they’re not able to respond and tell me otherwise, if they’re in an ICU on a ventilator, and I see that has been the pattern, then the likelihood of me continuing that pattern is much greater than if I had not seen that. So that’s where I feel a secondary risk to patients comes in, is because it alters the clinical judgment and decision making. 

Terri: Absolutely. Yeah. It might cause the physician to respond as well. Well, this is barely holding them, so let’s increase the dose, and then you’ve got another problem on top of that. But it’s the same idea. I think there’s another risk as well, and that is if the nurse is taking part in those medications while they are at work and working impaired, then you have a risk to patient safety just simply by the fact that you have an impaired healthcare professional. So that’s a third layer of the risk.

Michael: Yeah. Not only is it making good decision-making on the part of the not impaired people more difficult, but the primary person is becoming impaired. 

Terri: Exactly. Yeah. It really affects the whole team. I mean, you could take it even one step further in terms of if I’m working with a peer that is impaired or can think of nothing else but getting out of there to get their hands on some substance. I have to pick up the slack because maybe they didn’t do it well, or I have to finish their documentation, or they just can’t seem to get their work right. And so that impacts perhaps my patient load and my workload because I’ve got to help this other person get things done. So that’s another piece of it that we might see. 

Michael: And I think to really kind of dig in a little to what some of those risks would be, I imagine just from knowing what opiates do with people, that some of the things lost in a person who’s using would be the integrity of double checks. Because there are so many double checks, especially in the intensive care unit setting, when you’re looking at verifying the pump programs that are there, verifying the waste, verifying the doses. Nurses are getting asked for double-checks all the time. And so I imagine that a person, even if they’re mildly impaired, their capacity to perform an adequate double check is probably one of the first things that’s going to go. 

Terri: Yeah. I mean, there’s really probably nothing about their work that is terribly fine-tuned at that point. But you’re right, they don’t want to be doing double-checks to begin with. And then both of them, right. I mean, the person asking for the check and the person doing the checking, I think there are some that take it seriously, I’m sure, but I think there are many others that look at it as just something that gets in their way. So it goes pretty quickly to begin with, let alone if one of them is impaired. 

Michael: I think this is a great discussion and I want to come back to it, but I want to bring in another context to it just for a moment, which is some of the barriers that people express about speaking up when they observe a staff member when they see something that’s a little strange. There are a lot of things that a person may experience that are disincentives to saying something. They may be afraid of having, you know, shoot the messenger if they say something, that they’ll be implicated in whatever’s going on or be considered an accomplice. They may be afraid of being labeled a snitch or losing team respect or being wrong and hurting someone else, casting their suspicion on that other person. And so part of this discussion and the reason why I’m looking at some of the secondary aspects of what other nurses feel? Why would something like double checks be compromised? Is a way to help expand the awareness that saying something goes far beyond just that immediate thing that you’re looking at. Because when you have an impaired person, it’s affecting everybody. It’s not just the patients. It’s not just that person. It’s your ability to do work as well. And so when you speak up for safety, it really is on behalf of yourself, on behalf of that other person, and on behalf of your patients. 

Terri: Absolutely. I mean, first of all licensed professionals have an obligation to report. The Board of Nursing states that nurses have a responsibility to their patients, pharmacists, same physicians. The DEA states that any licensee that handles controlled substances is required to speak up if they see and they have a concern, or they could lose their privilege to handle controlled substances. So there’s a regulatory component to it, but let’s set that aside. That’s easy to ignore. People maybe don’t even think about that. When they got their license, it was done and gone. But there’s then the patient safety aspect of it that we need to care about our patients and we don’t want to see any harm. But you’re completely right, Michael. There is a peer aspect to it. And really, even just simply the fact that my peer that I’m working with and probably have some sort of a relationship with, depending on how long we’ve worked together, they’re at profound risk for morbidity and mortality. And to let this go on not only puts a patient at risk but puts that healthcare person at risk. And so we have to think of that. But also yes, to your point, if I don’t say something, I am enabling them, but they are also putting me at risk for policy breaches, for my own safety, finding perhaps a needle in a place where it’s not supposed to be. Or you’re right. If they’re my double check and I make a mistake. Now we have co-ownership for that drip that has just run at an incorrect rate and maybe perhaps caused patient harm. And so they’ve put me in that position of patient harm. So there are all kinds of reasons why somebody needs to speak up. But I think it’s also really easy for people to find excuses. We’re all going through things in life and if it happens to coincide, those changes in behavior with divorce or a recent injury or trouble with kids, who knows? We all have all kinds of things going on. And so if I start to see somebody whose behaviors are changing but they also have some of these life stressors, it’s much easier for me to say, oh, well, they’re going through this right now. I’m sure that’s all it is because we don’t want to think the worst of a substance use disorder. But it really comes down to that, looking for those changes and those patterns and then trusting our leadership to hold that concern in confidence and to do that thorough investigation to look into the matter. And then it’s I’ve said something, I haven’t accused, I have told you my concerns and why I’m concerned now. Leadership, you take it and you do that thorough investigation. And if it turns out to be nothing, my peer doesn’t know I said anything, but I have said something and that was my responsibility. And then we continue on. And they can work with that person that maybe isn’t working impaired and diverting, but has some other things that are affecting their work and they can work on improving those things. But those are, I think, all the things that go through the heads and the minds of those peers that are kind of stuck in that middle. 

Michael: You just laid out like six different pathways to go down. Finish the one on the diversion pathways, because I think understanding the pathways, and understanding some of the downstream effects in patient safety gives the other nurses who are not diverting some signals and things to look at that they may not have considered as signals before. 

Terri: Sure. 

Michael: And so for example, in that first one, when there’s false documenting, when you give somebody that PR ed med and it completely snows them and they’re out, it makes you wonder, well then how are they getting that every 2 hours before? 

Terri: Very true. 

Michael: What’s going on here? And so that’s an example of using that possibility now as part of that differential to try to understand what’s happening with the patient. 

Terri: Yeah, that’s a good point, being in tune for that. 

Michael: So when we look at substitution and you’re changing one out for another, you get some of the similar kinds of things as false documenting because you’ll have this documented administration of something that wasn’t actually there. The other thing that you see is access in the automated dispensing cabinet for multiple medications, one of which would be controlled and one of which would not. Typically, they’re going to grab both of them at the same time. And so if you’re a person who is kind of investigating or looking into that, looking for simultaneous withdrawals of tylenol and oxycodone, simultaneous withdrawals of diphenhydramine and fentanyl, these kinds of simultaneous withdrawals may often herald a substitution type of phenomena. 

Terri: Absolutely. 

Michael:  Duffinhydamine injectable is a great substitute when you think about the drowsiness that it can induce that is going to make a person feel like they are seeing us depressed. Absolutely. It’s the anticholinergic side effect of diphenhydramine. 

Terri: Right. 

Michael: And it’s going to mask and mimic the fact that they didn’t get an opiate, but they’re still going to feel drowsy and they’re going to think, well, maybe my pain was just really bad. 

Terri: Right. And let’s not forget, when we’re looking for those patterns, they may have canceled that removal of that noncontrolled substance, so canceled in terms of automated dispensing machine, but they really did remove it. They have it physically, but you may not see the actual removal. It’s like, oh, they canceled it, they changed their mind. But let’s look for those patterns as well, because that may be how they do it without letting you know they have removed it, when indeed they have because we don’t count those. Right, right. 

Michael: Or you’ll see a return of that ibuprofen or acetaminophen only, because when both of them are taken and only one is charted, it begs the question, so what happened to the other? And if they document that return, it doesn’t raise that red flag or question. It would require an actual manual count, cycle count in that machine to detect that discrepancy. And really, nobody’s doing that with acetaminophen. 

Terri: Right, that’s true. Yeah. 

Michael:  So I think the takeaway for some of the practicing nurses and things to look for when it comes to substitution is very similar to false documenting. However, you may be seeing some bundled transactions together, or you see somebody who is routinely you’ll see them carrying things in their pocket because they’ll have a little stash of that acetaminophen, or they’ll have a little stash of the ibuprofen to use as an alternative when they’re substituting. 

Terri: I think another sign, too, is if another nurse has administered charting and administration and removed a med on your patient, perhaps you went on a break, they weren’t covering for you, or you just noticed something on your Mar that’s like, I didn’t remove that, and give that it’s like, why are you taking care of my patient? And I’ve seen that, too. And that’s when the peer questions that single transaction that then leads to that fuller investigation and you start seeing more things like that. But it’s another example of that astute peer that notices something is off. 

Michael: Yes. And then another one is to access the order that calls for that two percocet or two oxycodone, but then only chart the one. Yes. Then you had mentioned the waste, and there are, I think, a couple of categories of waste because you have your unit dose waste. There’s the half tablet. We’re not going to see that. At least I don’t see so much wasting with the tablets as much as I do the injectables where you’ll have that clear fluid. 

Terri: I’ll tell you a story. There’s one case that I’m familiar with where a nurse wasted a tablet. I don’t recall if it was a half or a whole, but they were wasting it. And the witness did their job. They were watching the entire time and they noticed that the waster never opened their hand over the waste bin. And she called her out, hey, open your hand. And the tablet was still in the hand. It was never going to make it to the waste bin. So you’re right, I think we don’t see that as often, but it is possible. 

Michael: Yes. So with the injectables, there are two different categories for those because we have not just the vials, the syringes. Here are a couple of MLS of waste. We certainly see that frequently. The other one that is difficult to get to is the bags and the tubing and the wasting of the PCA canisters. The wasting of the controlled substance infusions – those are a gold mine for folks who are diverting waste because they can siphon off large quantities through that process. 

Terri: Yeah. And unless a facility has a standard process in terms of tubing volume and how they’re handling things, it’s easy to say, oh, we’re off by saying it’s in the tubing and that’s that. So you’re right, it’s a gold mine. 

Michael: Well, Tubing holds 20 MLS. If you get a fentanyl, 50 mic per mil infusion going, that’s a milligram of fentanyl you can siphon off. It’s huge. Do you have any best practices that you know of for managing the waste in those controlled substance infusions? 

Terri: I have not come across any best practices. I know that some facilities choose to change tubing every time or keep it consistent. So when they are doing the math, they know exactly when that tubing as opposed to every 48 or 72 hours, and then they’re messing with all of that. So in that type of consistency, they’re looking to just make it a little bit easier to not play the guessing game in terms of those tubing amounts. But outside of that, in terms of the waste, no, I haven’t seen anything too novel. Have you, have you run across anything? 

Michael: Oh, I’ve toyed with the very inefficient idea of having the waste measured just withdraw into a syringe what is in the bag, in the vial and what have you, because the tubing amount is a known amount and so you can add the two together to have a much better approximation of what’s being wasted than current practice. 

Terri: Right? Yeah. Any of you listeners out there, if you’ve got any ideas, you be sure and let us know. 

Michael: Yeah, like I said, it’s more of it feels extreme and it would be extraordinarily time intensive compared to the current and I think it’s probably something you’d only want to do temporarily if there was felt to be a concern. The other opportunities that I see are the spaces where there is just a single person who’s left alone with that narcotic confusion. Whether it’s from the place where it’s prepared usually the med room to the patient’s room, or when it’s being taken down from the patient’s room to the med room. The opportunities for things to disappear in those times. So I think we’re very focused on having a witness in the waste but we don’t have a witness of when it got to the place where it’s being wasted. 

Terri: True. Yeah. And sometimes we find, I’m sure you do too, find a bag that is just hanging in a room after a patient is gone and nobody has taken it down and those are opportunities too. And then you’ve got EVs and everybody walking through there and that’s ripe. 

Michael: So what are some of the more effective deterrence that you’ve seen with respect to mitigating some of the diversion behaviors that occur and are there some that are more specific to a particular care setting than another? 

Terri: That’s a good question about more particular to a care setting. I don’t think so. I think that in procedural areas and or areas I feel in my experience they tend to be more of this we’re a family, get out of here, we take care of our own. And I think it’s just maybe personality types and stuff in those settings. But I think there are so many different layers and peer education as to the fact that diversion occurs right. And how prevalent it can be based on the statistics of healthcare workers having a ten and now they’re saying as much as 20% chance of a substance use disorder and so they’re just like the rest of the population. Just because they have a professional license doesn’t mean that they’re immune to this. And so starting with everybody at the bedside leadership, everyone understanding that this is a thing and we need to be cognizant of it and what the signs are and then having a culture in place where we can feel safe to report our concerns and know that they will be held in confidence and investigated thoroughly. So I think that is the cornerstone of the whole program. And really, I think to a large extent, if that is all you did, and you really had a healthy, robust understanding and buy-in from everybody and coming from a place of empathy in terms of you’re my colleague, and if I get concerned, then I’m going to speak up because I care for you, not because I found you. I got you. Don’t do that. But from a place of empathy, I think if we can get that nailed down, that can take care of a lot of it. So that is one big mitigation piece of it. The other is really making sure that we define things in our workflows and policies and procedures. Because if somebody is educated to proper workflow policies and procedures it doesn’t mean they’re going to follow them. But if we get people to understand why they’re important and why they need to follow them, then when we find somebody who isn’t following they will stand out more. And on top of that, it gives us something to hold them accountable to. So you can begin to have that discussion because as I’m sure you know, Michael, poor practice can look like diversion and vice versa, right? And so when I go to interview that person and they say oh, I didn’t know that I had to waste in 30 minutes, it’s been 6 hours, it’s like really? Did you not know? So we want to make sure that we have that education and we know that they’ve been educated so we can hold them to that. So that’s why we need our strong policies and procedures. So those two things I think will help you find a lot. On top of that then it’s not so much the mitigation but more the monitoring. We need to be looking because people will find ways around it and they’re smart, 24/7, they’re thinking about how they can cover their tracks and get away with this. So we are going to miss it sometimes and so we have to monitor and that is through auditing of some sort and doing those deeper dives on people whose numbers are just a little wonky and they don’t quite match what everybody else has. So those are just some of those things. But it’s definitely a multilayered process for sure and a cultural the better your culture is to encourage reporting and self-reporting, the more successful you’re going to. 

Michael: Because people will speak up, 100% agree. And if I work through that backwards a little bit with the monitoring, I feel like making the monitoring transparent to be upfront to say yes, we’re monitoring this, we’re not hiding anything. You can see what it is that we’re monitoring. It’s like driving and seeing a police car on the side of the road. It’s a reminder, don’t you, to do something crazy. And I think that in itself can be a deterrent and a mitigating factor for that. And then, as you said, use compassion to understand we’re not approaching this with the idea of got you wrong. So I won’t say be human about it. Understand that the people that have a substance use disorder are still people and there are reasons that are driving them in the incentive structure that are prompting that behavior. Because whenever you get down into that person’s shoes to the point where you feel like or you can understand that what it is that they’re doing feels like it’s the best thing that they could do at that moment. And when they do horrible things. That is a scary place to be when that horrible thing is the best thing you can do at that moment. What kind of life is that? And that’s, I think, part of the understanding that we can bring to that while still keeping in context. Yes, we absolutely need to find this. We need to address it and sequester it because it affects peers, it affects patients, it’s affecting that person. 

Terri: Yes, agreed. I interviewed someone recently and she used the term your brain is hijacked, it’s just not thinking properly. 

Michael: So you talk a little bit about the workflows and poor processes and there are poor policies too. Bundle that one in there. And I don’t know if you’ve run across this, but Daniel Conneman, who was a Nobel Prize-winning and I’m not going to get what profession he was, he wrote a book and contributed to a book on noise and talks about the value of decreasing noise in systems to find variability. And that is exactly what we’re talking about when we say when you tighten up your processes, when you tighten up your policies and procedures and you decrease the noise, then it’s easier to see signals. 

Terri: Absolutely. 

Michael: So one of the best things that you can do, I think, when you’re trying to start with controlled substance surveillance and monitoring is first, clean up the usual practices. Tighten those up. 

Terri: Absolutely. That is crucial because especially what’s interesting is more and more people are getting the software surveillance packages and when you start to look at that, you’re going to see so many things and it’s very eye-opening. It’s not just, oh, they wasted late, but it’s literally they didn’t waste at all. It’s like, wow, there are a lot of people that are just careless with their controlled substance waste and you don’t realize that until you have a look into every single controlled substance transaction. Is somebody in there diverting? Probably. Are people just careless? Quite possibly. So that is just one example that I was really surprised to find the carelessness that you start to find when you have so much access to all the data. But absolutely, you’ve got to get that cleaned up first so that then you can see those outliers. The water is just too muddied if you don’t clean that up first. 

Michael: And thinking about some of the safety aspects of this as well. If I put myself in the nurse manager’s shoes, here I am, I’ve got a potential diversion situation. An employee who used to be my star employee, they volunteered for all the extra shifts and they were most helpful, especially if you had to give some morphine. She was right there. And now we’re looking at how to manage this unit and I’ve got someone telling me, well, you need to reinforce that policy and crackdown, and oh, by the way, you’re going to lose this person who contributes about 10% of your workload. But don’t worry, it’s. Going to be safer. And you’re thinking, well, how? Because now I’m short staffed and I have an unpalatable message to be giving people that not only are you short-staffed, but we’re going to crack down on these things that we never cracked down on before. But don’t worry, it’s for your good. How do we deliver that? 

Terri: Yeah, you’re spot on, especially a nurse manager that doesn’t buy into diversion and that it’s a thing. And if they’re presented with, say, that first task of data, like, I think we have a problem here, they first don’t really buy into it. They haven’t had any experience with it. They have had this employee that they have a great relationship with. They like them, and they cannot lose them because they’re short-staffed. And as far as they know, they’re a really good nurse. I mean, they’re making it work. The patients seem to be happy. They’re filling a shift. They’re the hustler, like you said, they do a lot of that extra work and that definitely plays into it. So I don’t think there’s any magic answer. Again, it comes down to that education piece that your leadership needs to understand. 

Michael: You have to get them to the point where they understand diversion and the importance of addressing it quickly. And then the onus, I think, is on the person leading the program who’s identified the person to just really say, look, I’m sorry, again, be empathetic with the manager who’s going to feel it, but we got to take this through to the end because we may have a problem here that puts everybody at risk. But that’s a hard one. That’s definitely hard I have definitely had no, or we can’t interview them tomorrow because we’re short and they’re working. It’s like we can’t let them work anymore. We have to do this tomorrow. It’s a big thing. It feels to me like it’s a great opportunity for leadership. When you mentioned that I could see a nursing director coming in and being able to put forth those values to say, no, this is a concern, this is a big deal. And it’s not just you and the unit. You have an entire hospital behind you that can support you. So we’ll find some people to fill those shifts. We’ll talk to this person and we’ll work it through. And I think that’s a great way, a great opportunity, I think, to send a positive message that doesn’t compromise the integrity of our values in that situation. 

Terri: Right, yeah, agreed. 

Michael: It goes all the way from leadership to the managers to the nurses to the frontline. Folks, the concerns are just everywhere. Now, you had mentioned some of the programming and the software, and I see the term artificial intelligence used, but I’m a little fuzzy on what exactly is, I guess, artificial and what is intelligent. 

Terri: Yeah, if you talk to the vendors, they’ll give you a little different terminology each 1 may say, something different. And yes, some will say I’m trying to think, I can’t think of the term that one of them used, but artificial plus human to put it together. But yeah, essentially what it’s looking for is if you can feed back to the software. So originally it’s just looking for the basics, right? Like did somebody dispense a lot more than somebody else? Did somebody waste a lot more than somebody else? Did somebody have a lot more full-dose waste than somebody else? And if that’s the case, then it will mark them as hey, you better look at them now. It doesn’t take into consideration off the top necessarily. Well, this person worked ten shifts and this person worked two, or a small unit that maybe only has two regular employees, but they have 20 people that float in and out. So your two people are always going to look bad, right? And so that’s the basic intelligence piece of it. But if the software allows you to comment like, okay, you found this person or maybe you didn’t find this person, but we found them and we do suspect diversion, whether highly suspected or admitted, then you can go back into that software and make a note, say yes, diversion. And so now that software can say, okay, let me look at nurse A because it ended up that they were diverting and let me look at all of their activity and see what they were doing and see if I can learn from that. So if you have one of the software that allows you to do something like that, then you can get even more of that intelligence. And then some of the companies, they don’t share the data with different facilities, but they can collate it all. So they may have maybe six large facility clients and now they have data for all six. That impacts the alerts that everybody’s going to get because it’s learned from that. But yeah, you can’t really have a lot of intelligence unless you have a lot of data, right? That’s how it gets smarter. So really they just kind of start with those basic principles and then hopefully build on it by what they learn from the people that they’re monitoring. 

Michael: So one of the challenges that I have encountered with the programs and I’m developing this brainstorm as we speak and as we talk. So if it’s not quite right or fully formed, that’s why there are a couple of drivers behind the metrics. One of them is this fascination with standard deviation that I see, and I see this in regulatory agencies, I see it in governing bodies where they’re looking at the standard deviation. And the problem that I guess and this is what I’m just coming out with, the problem is that the data isn’t normally distributed. I have a whole bunch of staff that are perfectly fine and I’ll have one person who forgot to waste and they just hit three standard deviations because one unit of medication is sufficiently variable when everybody else is zero. Correct. That it throws them into the bucket with a spotlight. 

Terri: Right. 

Michael: And I guess the concern that I have on the one hand is the potential for the data to be done correctly, but be misinterpreted as in there’s a problem when there isn’t a problem. And then the other is that the data is not being treated correctly as in standard deviations and it’s being interpreted. So those would represent false flag risks for normal staff. What kind of advice would we have for the staff? Number one, to kind of calm down, cool your jets. This is a tool, it’s not the judge, jury and executioner. And what kinds of things should staff begin to be thinking of in their normal workflow practices that can help not trigger those things falsely? 

Terri: Yeah, I think that ideally, whatever software you have, your vendor will have worked with you to match your policies and procedures. So let’s say that you give your people 60 minutes to waste something, then nothing’s going to trigger until past 60 minutes. So I think really the message to staff who are being monitored is really just follow policies and procedures. I mean, if you follow those and then you should be fine. If you identify something that falls outside, then once you investigate, you might find that let’s say it’s a procedural unit and on weekends or evenings, there’s no other nurse to witness the waste in the automated dispensing machine and so there’s no one to waste them with. So they do it on paper with somebody else, let’s say, that doesn’t have access, or maybe the physician won’t do it in the automated dispensing machine, but they’ll sign a piece of paper for you so it looks like missing waste, but meanwhile they have filled out the paper, right? So you might start to figure out some of these workflows that you’d better off fixing and correcting. So you’d get rid of some of these false flags. But the message to staff is follow best practice and policies and procedures and you should be fine. Now, we’re all human, we make mistakes. So, yeah, I might forget one time to do it, or do it late one time because there was an emergency of some sort and I couldn’t get to it and so it was late, so I will fall out. Then it comes to the vendor of your software. How much emphasis do they put on a particular fallout and how will they rank it? And so that’s something else to consider to work with your vendor. But you’re absolutely right. I think the key is the people who are monitoring the software need to be fully educated on what they need to do first before they raise the red flag of oh my gosh, we have a problem here. And I think some people are under the impression that if you turn on the software, your job is done. Your job is just beginning. When you turn on the software, yes. It helps you identify people that you should look at, maybe faster, and it’s more comprehensive and you can look at the data and is this a unit person, a unit issue, or an individual issue. In other words, do they all have this poor practice on the unit because that’s kind of the culture or is this a standout person? So you have all of that data at your fingertips, but that’s just the beginning of the work. And so I know that when I’m monitoring, I provide a service. It’s a centralized diversion, monitoring as a service, meaning I’ll do it for you from a central location and give you that expertise. But I know when I start to look, my first pass is a quick, let me look at everything and see if this really looks to be something or if the software has identified them for what looks to be. I can find a reason. Perhaps maybe it’s the shifts or maybe it’s a person that was on a drip of some sort and they happen to work three shifts and that’s why their numbers are higher or whatever the reason is, you got to do that first pass. And then if you find, okay, that explains it. But if not, then you start to dig down. But you still need somebody to dig down before you start saying to the manager, you have a problem here just based off of the first pass numbers because sometimes they’re wrong, sometimes oftentimes, yeah. 

Michael: They’re the tip of the iceberg, but we have to find the rest of the iceberg. 

Terri: Right. 

Michael: And you’re so right about just taking the time to go through and make sure that these numbers are to test them. Trust but verify, right? 

Terri: Well, because if you don’t do that, it’s the boy that cried wolf, right? When I do see something, if I’ve given you all these others that it’s like, well, look at this. Then when there is a problem, nobody’s going to listen to you because you’ve cried Walt so many times. 

Michael: And I think for the nurses that may be on the receiving end of communications about that in this software, 100% follow the policy and procedure. Most of that artificial intelligence, most of the surveillance programs are configured in ways that are compatible with existing policies and procedures such that if you don’t have events or activities that are violating policies and procedures, then you’re probably not going to show up on that monitoring software. But the other thing I would really want to drive home with nurses is don’t assume that all the software that you use talks to each other because your electronic medical record is going to say, hey, you missed a dose. And then your automated dispensing cabinet is going to say, hey, you have a discrepancy. Those 2 may not be talking to each other in the way that you think they are. And then on top of that, you have a surveillance program that’s taking data from both of them that’s going to say, hey, we have a discrepancy. So just because you fixed it in one doesn’t necessarily mean it’s going to talk flow over to the other two or three, depending on how those systems are configured. 

Terri: Yeah, well, that’s an important piece, I think, for leadership to make sure they have buttoned down before they add one more thing on top of it, because otherwise you’re going to get false positives here. Now the person doing the monitoring is going to start not to trust anything. 

 Michael: Right, you get somebody that said, but I resolved that discrepancy in the automated dispensing cabinet. Well, that’s good, but the cabinet doesn’t talk to wherever that was, just account. So I think that one is the policies, the other is to understand that these systems aren’t talking to each other and I think to be armed with that is especially helpful. 

Terri: Yes, absolutely. Yeah. Well, this was a great conversation. Thank you, Michael, for doing this. It was great. And I want to thank everybody that was listening. I hope that you guys all got something from it because as we said, it’s definitely a safety issue when it comes to diversion. So those of you out there, hit that subscribe button. And I want to thank our sponsor, IMI, the manufacturer of the industry-leading prep lock line of Tamper evident caps, which are an active deterrent to diversion, as well as a product that serves to guard the sterility and integrity of medications and you can learn more about them@imiweb.com. So. Thank you, Michael. Any last words that you want to add? 

Michael: I would encourage folks to check out the podcast. Amspod.com is a website. The podcast is applied medication safety. And join the discussion. Thank you so much, Terri. I greatly appreciate this and I learned quite a bit from this as well. 

Terri: Yeah, me too. And those of you that are listening, if you do have any feedback or comments on what we talked about, definitely share shows with us because we don’t know it all and you talk to somebody and you learn something new. So we’d love to hear from you guys. All right. Thank you, Michael. 

For more information and resources on drug diversion, visit https://www.rxpert.solutions/

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Terri Vidals
Terri Vidals

Terri has been a pharmacist for over 30 years and is a drug diversion mitigation and monitoring subject matter expert. Her years of experience in various roles within hospital pharmacy have given her real-world insight into risk, compliance, and regulatory requirements, as well as best practices for medication and patient safety.

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