Drug diversion in surgery is a growing concern. It's not only because people are looking to get high or to feed their addictions by lifting a few OxyContins, drinking a few sips of Demerol left over from a case and recording it as "waste" or taking a syringe of fentanyl off the sterile field and replacing it with a needle full of sterile saline solution hidden in a scrub pocket (tinyurl.com/kej3lcf). There's also a profit to be made, as in the case of the pharmacy technician at the University of Miami's Sylvester Comprehensive Cancer Center who for 3 years pocketed boxes of Neulasta (pegfilgrastim), a medication used to boost white blood cells to reduce the risk of infection. Neulasta costs about $2,600 per dose. The tech is accused of stealing more than $14 million in cancer drugs and selling them on the black market. Fortunately, as drug diversion has gotten more sophisticated, locking anesthesia carts that closely track drugs and keep them secure have gotten more sophisticated as well.
Make it easy to do the right thing
Ideally, in addition to security, your anesthesia cart should provide accountability. Alone, a locking secure cart won't protect providers who abuse. That's where you need a drug accountability system that goes along with the locking cart, one that provides a set of checks and balances to protect their contents against theft, unmonitored use and tampering. Some carts even include a separately securable drawer or section that lets providers lock down their morphine, fentanyl and other controlled substances at all times. But just because a cart has a lock doesn't mean it's effective against diversion. This calls to mind the case of the hospital's chief of anesthesiology who was undermedicating his patients during surgery and taking the rest for himself.
Be sure to select a cart that's easy to lock and unlock, and doesn't disrupt your workflow. Make it easy to do the right thing. It's a motto that I use. Your system is only as good as users' ability or willingness to comply with your equipment. If an anesthesia cart is not easy for your providers to use correctly, they'll stop using it after a week. In 2005, my hospital bought a fantastically expensive dispensing system. After a year in use, we found a very low usage rate. The problem? It was dependent on the OR's spotty wireless connectivity to work properly.
CMS doesn't require you to have a locking anesthesia cart, but if an operating room is not in use, the facility is expected to lock non-mobile carts and ensure mobile carts are in a locked room when not in use. The operating room suite is considered secure when the suite is staffed and staff is actively providing patient care. When the suite is not in use (weekends, holidays and after hours, for example), it wouldn't be considered secure. So when is an OR considered to be not secure? The moment the last licensed person walks out of the OR, it's no longer secure.
People who divert drugs are pretty clever at figuring out ways to get around what you may think are very good drug security policies. Your cart should be able to scan bar codes that confirm the proper drug and proper dose. Some bar codes are more advanced, carrying lot numbers and expiration dates, and ensuring the potency of your drug.
Discovering this type of activity requires having strong medication safety and security systems in place. Enforce your witness waste program. You are the system's protector and defender. Don't just let somebody sign in on the computer that he wasted a partial dose. Witness him destroying the substance. Watch it go down the drain.
Swiping Demerol From the Narcotics Cabinet
I have a crafty nurse to thank for my job as the medication safety officer here at Lehigh Valley Hospital in Allentown, Pa. About 8 years ago, this nurse began stealing Demerol to feed her own drug habit. She'd punch in her 4-digit code to open the locked narcotics cabinet, cut a few tablets out of the unit dose containers and replace them with other tablets. Because the plastic coverings on the packages were amber, it was hard to see that she was replacing yellow pills with white ones.
To conceal her tampering, the nurse taped the Demerol packages together in strips of 10 so, she claimed, they'd be easier to count. She got away with this for 4 months. Eventually, though, somebody noticed that the packages were tampered with and that patients who received bogus pills were still complaining of pain.
Leroy Kromis, PharmD