Ed Holmes (ed.holmes@fairwarning.com) is chief executive officer at FairWarning in Clearwater, FL.
In the healthcare industry, 10%–15% of healthcare workers will misuse medication during their career.[1] Unfortunately, the real number is likely even higher because it is extremely difficult to quantify exactly how many incidents there truly are in a hospital setting. Double-digit diversion numbers coupled with incidents that fall through the cracks show that drug diversion is an enormous issue and a risk to patient safety, delivery of care, and compliance. Noncompliance with drug diversion regulations can lead to heavy fines and reputational damage. During the COVID-19 pandemic, this is a recipe for disaster, with hospitals in the US losing an estimated $200 billion by the end of June 2020.[2] The first line of defense in stopping drug diversion is to set up a drug diversion monitoring program.
Traditionally, drug diversion monitoring is a time-consuming and manual process, but today, with access to technology, it’s easier to tackle. As regulations continue to evolve in support of better patient care and medication controls, hospitals need diversion monitoring programs to comply with state and federal laws and guidelines. When adopting such a program, compliance professionals should ensure it includes proper controls for compliance while reducing the risks to patients, staff, and hospital operations. By also selecting technology that supports tracking the flow of medications, healthcare systems can proactively work toward monitoring 100% of transactions.
The correlation between hospital settings and drug diversion
Drug diversion cases can appear anywhere in the US, particularly in areas that have been harder hit by the opioid epidemic. These regions tend to be rural areas with less access to treatment.[3] Diverters can also be more common in institutions that don’t have as many controls—think nursing homes or home caregivers. However, what’s at the forefront of headlines and on the minds of the broader healthcare industry is how the pandemic has changed hospital operations and what this means for drug diversion. With more medical staff jumping from hospital to hospital to care for patients where needed, diversions have a greater chance of flying under the radar.
Hospitals that don’t have a drug diversion program will find it’s a lot harder to track diversion cases without the proper tools and policies. Tracking drug diversions isn’t just about stopping it from happening. It’s also about ensuring compliance with regulations set out by the Controlled Substances Act; Drug Enforcement Administration guidelines; The Joint Commission standards; and, for those that take Medicare programs, Centers for Medicare & Medicaid Services guidelines. The Controlled Substances Act of 1970[4] is one of the earliest sets of rules surrounding drug diversion, and it stipulates guidelines such as appropriate and timely wasting of unused drugs and daily reconciliation of drug transactions. Generally, most new pieces of regulation can be mapped back to this law.
Documentation is where one of the biggest gaps in compliance can happen in a hospital setting. A common scenario involving improper wasting is when a nurse disposes of unused medication at the time of administration, without a witness present, as is required by regulation, but has a second person act as the witness when the waste is documented in the record. Or, a nurse documents administering a full dose of medication to a patient but actually only administers part of the dose. Then, the nurse diverts the unused portion for personal use. Both of these scenarios can cause issues with the auditing process because if the paperwork isn’t correct, it can be deemed fraudulent billing, particularly for Medicaid and Medicare.
Another area where hospitals have a gap in compliance is internal policies surrounding drug diversion and proper medication handling. Discrepancies can happen when the supervising nurse doesn’t properly go through reports on a weekly basis to reconcile medication transactions. The Controlled Substances Act says that hospitals should be reconciling transactions daily,[5] but that doesn’t always happen. When it comes to a suspected case of diversion, there can also be a level of hesitancy by staff to act on it, whether it’s because they don’t feel comfortable “snitching” on a colleague or that they simply don’t believe that the suspect could divert (without clear proof to tell them otherwise).[6]
