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Surveyor Asked How Controlled Substances are Monitored

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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

Our References

Terri is absolutely phenomenal. She is an incredibly knowledgeable pharmacy resource. As the medication safety officer, the quality initiatives she implemented not only impacted the patients at our medical center but also reached into the community. Terri is a genuine professional who upholds accountability while creating community among her team members. She is a great listener to identify friction points and has actionable ideas to implement improvements.

Lab
T. Eagle. MBA, MLS(ASCP), CLS Lab Operations Manager

Terri is an expert at prospective risk identification -Failure, Mode and Effects Analysis (FMEA). Terri participated in CHPSO Patient Safety Safe Tables and was part of the Hospital Quality Institute’s Regional Quality and Patient Safety Leader Network.
She is an excellent public speaker and communicates well with public and professional audiences. I look forward to her continued work in medication safety.

Regional Quality Network at HQI
A. Munoz, FACHE, CPHQ, CPPS VP

Terri has done a tremendous job with the controlled substance diversion program. She has had such a positive impact and has really made the hospital a safer place.

Tri-City Medical Center
Nurse Manager

We would not be where we are with the improvements we have made with opioid prescribing if it were not for Terri driving the process.

Tri-City Emergency Medical Group
Chief Physician

In addition to understanding the ins and outs of the [controlled substance use] process completely, she is very proactive in coming to me with provider issues that she detects. She truly balances the administrative duties and the regulatory components demand with a keen sense of what my practitioners do and what their needs are on the ground. Terri is instrumental in working with my department, balancing patient care, cooperation, ability, and integrity to get the job done.

UCSD Medical Center
Chief Anesthesiologist

Terri is knowledgeable and effective in pharmacy leadership. She has the ability to be able to anticipate and prepare for the future. Her ability to utilize resources effectively in this changing environment is a strong asset. She can adapt, evolve, mentor and still never say “no” when asked to assist. She exhibits great abilities to be flexible and is a “self starter”. She has a pleasant yet effective demeanor that commands results.

Candace Fong, Pharm D
System Director of Pharmacy and Medication Safety Common Spirit Health

Terri has always impressed me as being very smart. resourceful, creative, and easy to work with. Terri’s commitment to medication safety permeated our organization, raising the awareness of this important issue throughout all levels of the institution. Terri has always been engaged, cooperative, and generous with her time.

Cary Mells, MD
Chairman of the Department of Emergency Medicine Tri-City Medical Center

Terri has done more for the Pharmacy in her few months as Interim Pharmacy Director than any other Director has done during my 12 years here.

Anita Kennedy, MBA
VP of Ancillary Services Methodist Hospital

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Address: 950 Boardwalk Suite 305, San Marcos, CA 92078

  • 760.705.4078
  • tvidals@rxpert.solutions