I recently read a report of an Emergency Department nursing director who was charged with unlawful dispensation of a controlled substance; failure to make, keep or furnish records; obtaining a controlled substance by fraud or deceit; and theft.[i] A quick Google search revealed a few more examples of Emergency Department staff who were caught diverting controlled drugs.[ii],[iii],[iv],[v] In each of these cases there are lessons for those of us who are continually working to find and close loopholes that can be exploited by those who are intent to divert.
Loophole #1. An effective diversion prevention and detection program should include a small, highly trained multidisciplinary team who are charged with analyzing and investigating suspected drug diversion. Many organizations will default to the nursing unit manager or director as the first line of review and investigation into suspected diversion. But what if the manager or director also has access to the controlled drugs in the ADM? In smaller hospitals, it is not unusual for the manager or director to be involved in providing patient care, which is perfectly fine unless they are also charged with oversight for diversion detection. Managers and directors have shown bias when reviewing ADM records that show unusual activity by one of their staff, and could potentially be alerted to investigations into their own behavior when they see the ADM reports. If the organization is unable to form a diversion investigation team without access to ADMs, it would be wise to ensure that reports are reviewed by disinterested parties, perhaps using managers to review different units, etc.
Loophole #2. Emergency Department encounters may not be closed in the record system for as long as 24 hours. We have found many hospitals leave the records open because staff and physicians need to come back later after the patient has left to complete the documentation. This creates an opportunity for controlled drug withdrawals for patients after discharge, with or without a post-dated order. If the hospital bills for drugs from the medication administration record, it is difficult to detect when an unauthorized withdrawal has occurred unless there is a process to reconcile drug withdrawal transactions to the orders, administration records, and waste records. Find out when the ED encounters are “discharged” or closed in your system. What is a reasonable amount of time to leave the record open? Work with the ED staff to determine the least amount of time. Establish an audit report that compares ADM transactions by patient and discharge time, and flag transactions that occur after the time the patient has left the department.
Loophole #3. Patients may not be registered in the Emergency Department prior to the start of care due to many reasons. Patients with unknown names are given pseudonyms until identity is confirmed, or staff may opt to “search” the universe of historical and future encounters in the system to “find” the right patient. When staff has access to all encounters this creates an opportunity to withdraw controlled drugs, perhaps for the right patient but wrong encounter, or even wrong patient /wrong encounter. If your system grants this level of access to your staff, it is important to set up an audit and error message to catch a transaction date mismatch, or a billing error. We have seen numerous drug diversion events from smart staff who have figured out this loophole.
Loophole #4. The last loophole is one that begins with convenience and ends with diversion. Typically, hospital staff are assigned access to the ADM machines that are physically located in the area they are assigned to work. Some hospitals will grant access to multiple ADM machines based on frequency of floating staff across areas, or because some physician providers work in multiple areas (ENDO, OB, OR, ED). This is a setting for convenience, and it negates an important security feature of the ADM. The purpose of restricting access to multiple ADMs is to improve control over access. When staff float to a new unit, a management person (charge nurse) will authorize temporary access that is limited for that shift. If your hospital routinely grants access across multiple ADMs, it would be prudent to analyze your ADM reports by provider as well as location and time of day. You may find that there is unusual activity where you least expect it, and when pooled with similar providers or staff may give a different picture than the standard location view.
Emergency Departments provide some unique access and opportunity points for drug diversion. Understanding how your systems are set up, how they are maintained, and having a process to monitor for unusual use is a key to preventing and detecting drug diversion.