Drugs are the forbidden fruit of the healthcare workplace, and they can't be avoided. I've read reports of an anesthesiologist who'd hooked himself up to an infusion pump of sedatives, set to shut off in 4 hours, in order to ensure he'd get some sleep in between long shifts. I've heard about how pre-filled morphine syringes and fentanyl ampoules can be tampered with so that the emptied containers look like packaging errors, not theft. I've noted inventory shrinkage in all pharmaceutical areas, not just among the painkillers but also among the acid reflux and erectile dysfunction drugs. And then there was the account of the surgical nurse who admitted to federal authorities that she emptied vials of fentanyl and refilled them with saline solution.

One foundation of any facility's drug security policy is a review of access to its drug storage. Who has access to the areas in which your drugs are stored, for whatever reasons?

Limited access
Not all instances of drug theft or misuse are perpetrated by physicians, nurses, pharmacists or other professional personnel. Keep in mind that it's possible for environmental services staffers, sales representatives and even contractors to gain access to your medications. Make sure that witnesses accompany anyone with limited authorization when they need to visit secured areas.

Establish a standard to prevent professional staff from handling controlled substances alone. Whether signing the receipt of medications or discarding unused remainders, surgical personnel carrying out actions with a witness are less likely to divert drug products.

You might also regularly rotate surgical staff assignments, working each member with different personnel so as to prevent staffers from colluding in drug diversions under the guise of witnessing its handling. Healthcare employees have been known to strike unscrupulous deals, looking the other way and covering for each other's thefts and misuses.

From an administrative level, you can maintain accountability by routinely comparing drug purchasing reports and billing summaries. There's no central recording system for what drugs are prescribed to patients, but there is one for what patients are billed for the drugs they've been administered. In an accurate count of the drug products that have come in and those that have gone out, you'll be able to detect any glaring errors.

Another basis for comparison is each staff member's usual care. If, for instance, the amount of drugs a nurse administers falls well above or well below the standard deviation of your entire nursing staff, an investigation may be in order.

Structure your drug security policy to reflect the fact that no one is above suspicion. A witness should accompany even the staff member charged with investigating discrepancies in order to maintain a system of checks and balances.

Another essential factor in your drug control policy is secure supply storage for floor stock and samples. In this area there are two options: manual and automated.

Manual storage includes locking carts or cabinets, a locked room, or both. Automated dispensing cabinets are computer-driven, requiring the user to type in a password or supply a biometric measure such as a thumbprint to gain entry.

There isn't a great difference between the two options in terms of the efficiency of the security they provide. As long as you have procedures robust enough to track the come-and-go of medication and you avoid the workarounds that stand to defeat each respective option, such as leaving a passively-locking cabinet or room open or posting the password near the dispenser, either should suffice.

If you discover a medication shortfall requiring investigation, an automated system can generate a report of who had access to the drugs, how often and for what purpose, while a manual system requires a painstaking examination of a paper trail and the questioning of employees. So while the security they provide is equivalent, automated systems can save time in accountability.

Cost is also a major difference, of course. While manually locking carts and cabinets can cost you hundreds or perhaps thousands of dollars, automated drug dispensing systems can easily range into the tens of thousands of dollars. Since this is equipment for which you won't be reimbursed directly — that is to say, storage doesn't earn facility fees — small practices and facilities with fewer employees may find it difficult to justify the cost of some high-end automated solutions.

Remember to extend security to needles, syringes, physicians' prescription pads and other medication accessories in your storage rooms, as these are also highly divertible, large-loss inventory items. Finally, the manner in which drugs are distributed can differ greatly between hospitals and surgery centers and may affect how they must be secured. While medications are fairly centralized in surgery centers — stored either in supply rooms or ORs and administered directly to the case at hand — they're more decentralized in hospitals, distributed by the pharmacy through the departments and kept in many locations.

The help they need
Nearly every practice and facility possesses controlled substances for legitimate treatment purposes. They become a hazard to employees when the security surrounding them is lax. An employee who steals a dose of painkiller is likely to repeat her action if she's not caught, even if she only intends to take 1 tablet, 1 time, because drug addiction literally changes the way a person thinks and behaves. The drug's effects may adversely affect the employee and the care they provide patients, as well as their career and their life.

After you've addressed control, accountability and enforcement measures, include in your drug security policy efforts to protect your staff from themselves. An employee-assistance program for staff members suffering from drug addiction should be available. In our hospital network, an employee who admits to such a problem won't necessarily lose her job, though she'll be subject to different work arrangements, random drug tests and other security measures. And in the end, she'll get the help she needs.