Surveyor Asked How Controlled Substances are Monitored

Fellow pharmacists are a wealth of information, and it’s nice when you’re part of a group that shares freely on what the latest surveyor focused on and lessons they learned. Within the last couple of months, two different hospitals have had surveyors that asked them how they monitor their controlled substances (CS) for accountability purposes. In other words, how do they track supply to confirm there is no diversion taking place? Although there may be inquiries into CS storage, accessibility, and ordering/dispensing during the survey, diversion risk is not a topic I have heard covered during a survey in the past. 

I am glad they are asking the question. Diversion, and the impaired healthcare worker that usually goes hand in hand with diversion, is a real risk to patient safety. If facilities do not adhere to processes in place to minimize and detect diversion, they are not doing all they can to keep their patients safe. I say “adhere to processes” because how many times have we had defined processes only to find out they aren’t being followed? Many times!

In the first speech I delivered as health secretary, I made one thing perfectly clear: we need a cultural shift in the NHS: from a culture mainly responsive to orders from the top down to one responsive to patients, in which patient safety is put first. –Andrew Lansley

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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