Penrose-St. Francis Health Services

All official Penrose-St. Francis Healthcare Services guidelines are maintained electronically and are subject to change. No printed guideline should be taken as the official guideline except to the extent it is consistent with the current guideline that is electronically maintained.

PENROSE-ST. FRANCIS HEALTH SERVICES

INTERDISCIPLINARY PRACTICES

SUBJECT: Drug Diversion (Investigation of)

PREVIOUS DATE: 6/07 EFFECTIVE DATE: 1/10

RECOMMENDED BY: Interdisciplinary Practice Committee

ADMINISTRATION APPROVAL: Jeff Oram-Smith, MD, CMO Katherine D McCord, RN, CNO

Guideline for Care: A process will be in place to monitor the use and potential diversion of controlled/ scheduled drugs. The Pandora reports and other means will be used as a means to monitor diversion of drugs.

Practices:

1.  Each month, the Pharmacy will print an Anomalous Usage Report via the pharmacy’s Pandora software. This is a running three month report that documents the total quantities of all controlled drugs vended from Pyxis Medstations during that time. The report is run for all facilities and all areas that have a Pyxis Medstation.

2.  The Anomalous report will be sent via e-mail to all members of the Controlled Drug Audit Committee

(CDAC) This committee is comprised of the Director of Pharmacy, Pharmacy managers Patient Safety/Risk Management staff, Vice President of Nursing SFMC, Directors of Nursing PH/SFHC and the CNO.

3.  The CDAC members receive and review the Anomalous Usage Report approximately 1 week prior to the next scheduled meeting. If the reviewers see anything immediately alarming, it will be addressed before the meeting.

4.  During the committee meeting, the reports are reviewed and discussed. The Anomalous Usage Report will show a medication name and a bar graph of associates that have withdrawn that particular medication in quantities above the average or mean. Users approaching or exceeding the “Upper Outer Fence” (UOF) are considered as outliers and may represent possible diversion prospects. The number at the left of the bar is the quantity removed within the report period. The following will be considered when reviewing the reports:

·  Usage that is greater than the UOF

·  Overall quantity that is substantially higher than those of peers

·  Frequency with more than one drug above the upper outer fence (UOF)

·  Repeated (more than one month report) incidence of same associate as an outlier in usage

5.  When associates are identified as being potential diversion prospects, the following will occur:

·  A Pandora Drug Activity report specific to the associate and drugs in question will be generated.

·  The report will be reviewed to examine variations in dosing quantities, frequency of administration, use of overrides, witnessing of waste patients treated, etc,

·  If decision is made to pursue further, Risk Management will then contact the Clinical Manager of the unit.

·  A recommended 5-10 charts will be selected to be retrieved from Medical Records

·  Risk Management and the Clinical Manager will review them together.

6.  After the medical records are obtained, they will be reviewed for the following;

·  Frequent removal by override

·  Appropriate documentation of wasting with a witness or lack thereof

·  Ensuring that physician order matches medication being administered to patient

·  Correlation of removal activity with documentation looking at variances of the date and time of medication withdrawal from Pyxis compared to time documented in the patient’s e-MAR

·  If for range orders for pain control e.g. “administer 2-8 mg Morphine for pain and the associate frequently uses the upper most limits on all patients especially when it is their medication of choice.

·  Significant difference in documentation of pain assessment score from one shift to another. Diverter will report “patient pain 10/10” while another shift may report pain control or lower numbers.

·  Removals occur at or shorter than minimum intervals ordered

·  Associate has reason for high quantity of removal—e.g. works more hours, cares for specific population etc.

·  Presence of written physician order versus frequent verbal/phone orders for medication under review.

7.  Following the chart reviews, if there is a reasonable suspicion, the results are discussed with the Pharmacy Director, Nursing Director, Nursing Manager, Vice President of Nursing (SFMC) and CNO as to reasonableness of drug screening. If diversion is documented, the Chief Executive office will also be notified. The hospital reports abuses and losses of controlled substances, in accordance with law and regulation,

8.  Other factors are also considered in this discussion, behavior, attendance, quality of documentation, etc

9.  Drug Screen per policy for reasonable suspicion.

REFERENCES:

“Prevention of Controlled Substance Diversion – Scope, Strategy, and Tactics

Hospital Pharmacy Vol 42, Number 4 pp 359-367, April 2007

IDP D-03-k