Purposeful CS Diversion Monitoring

Starting up a comprehensive controlled substance monitoring program is rewarding.  Its success can be directly measured by comparing your baseline of staff suspected (or confirmed) of diversion pre and post program implementation.  I am in the middle of starting up a program, and I have the privilege of working with a pharmacist who understands the need for the program, the desire to take ownership of it, and the traits to implement it. 

There are clear qualifications needed to be able to perform thorough audits.  I learned this the hard way, as I have worked with three fantastic pharmacy technicians who had the inherent skill needed.  However, I have also worked with a few who did not. They performed well as technicians with traditional technician duties, but did not have the characteristics needed to be good auditors.  In addition to the baseline skills needed, time is needed to hone in on the intuitive factor that makes a big difference to success ultimately. 

With this new program we are in the early days. We are working on the basics of establishing the program as well as what to watch for when performing audits.  The pharmacy has taken over the responsibility for detailed nurse CS activity review, as opposed to the previous process of relying on the nurse manager to perform that review. We are taking it slow because there is not yet the bandwidth to dedicate a full time pharmacist to this program, but we did not want to wait too long, so we have started doing what we can with the current resources. 

Don’t wait until everything is just right. It will never be perfect. There will always be challenges, obstacles and less than perfect conditions. So what. Get started now. With each step you take, you will grow stronger and stronger, more and more skilled, more and more self-confident and more and more successful. –Mark Victor Hansen

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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