Protecting your patients, staff and facility from the harmful effects of drug diversion and abuse requires a two-pronged strategy. First, you must effectively secure your medications and limit their access. Second, you must have a way to monitor medication inventory and detect any suspicious signs of diversion. Automatic medication dispensing systems coupled with database and reporting software can make it much easier for you to achieve these goals.
Dispensing cabinets: How do they work?
Drug diversion is an unfortunate risk all surgical facilities face because of the powerful nature of the medications they stock. Staff who are undergoing enormous pressure in their professional or personal lives or who have a history of drug abuse that you don't know about can be tempted by the all-too-easy access they have every day to narcotics and other potentially addictive substances. Auto-mated medication dispensing systems let you secure your drug supplies by keeping them under lock and key at all times and recording data each time someone accesses the system. At my hospital, we store about 95% of the medications typically used on a given unit not just controlled substances in secure cabinets to maximize the benefits of the system. Let's examine how these systems work in practice.
- Limited access. Users must enter a personal access code or, ideally, a biometric identifier such as a fingerprint to dispense drugs from the system. Biometrics are preferable from a security standpoint, but in some cases you may find that a nurse's fingerprint won't scan properly and she'll have to use an access code instead. Change these codes every 3 months or so for added security.
- Electronic data flow. At my hospital, after the prescribing physician or the pharmacist enters drug orders, the order is then transferred from the hospital's information system to the medication dispensing cabinets. When the nurse is alerted that there's a new order for a patient, she can go to the cabinet, log in with her biometric or access code, and call up the order along with a medication profile specifically tailored to that patient. When she selects the drug to be dispensed, the nurse may be asked some additional questions about the drug or the patient depending on the situation. Once the nurse answers any questions and she selects the quantity of medication needed, a light sensor identifies the location where the medication is housed and lets the nurse retrieve the order.
- Discrepancy detection. The system requires the nurse to enter the remaining balance of the drug after she has taken what the order requires. If that number doesn't agree with what the system shows should be there, the discrepancy is recorded and an icon is immediately displayed on the screen showing that this discrepancy has occurred. This allows us to immediately investigate any issues and track our drug inventories, particularly controlled substances, on a day-to-day basis.
Narrowing your search
While the cabinets themselves can detect discrepancies and alert you to suspicious behavior, you'll need to perform a more robust analysis of the patterns of drug access and usage at your facility to truly get a leg up on those who would seek to abuse the system. That's where drug diversion monitoring software comes into play.
These software systems essentially function as a database that lets us pull any and all fields of information from the automated medication dispensing system in a quick, organized manner. That way, when we do audits on medication usage, we can easily focus in on a particular individual, drug or process. When there's a discrepancy or issue, we can check the data from the medication dispensing system against our medical records and operative reports to find out, for example, if a particular drug that was ordered and dispensed was ever actually administered to the patient.
For an example of how these data gathering and reporting capabilities can help you root out diversion, consider the situation at St. John's Regional Medical Center when I first joined the facility 4 years ago. At the time, policies did not require nurses to have a witness present for an override involving narcotics an override being an instance where the nurse needs a medication immediately and can't wait for the pharmacist to enter the order. I instituted a change in policy requiring that all overrides must have a witness present, and then began auditing overrides from the past and present using the drug diversion monitoring software. A number of nurses, prior to implementation of the witness policy for overrides, were detected accessing drugs frequently without proper review of their overrides, indicating a pattern of diversion. Once we realized there were at least 3 employees who appeared to be diverting drugs, we instituted a policy of conducting weekly random audits of all employees who have been granted access to the system to ensure that medications dispensed from the automated system were actually ordered and given to the patient for whom they were ordered.
Checks and balances
Automated medication dispensing solutions won't completely replace the need for you to keep your eyes and ears open to potential warning signs of medication theft. Combining automated tracking technologies with standard policies and procedures for drug orders and medication reconciliation helps to create a system of checks and balances that thoroughly protects your facility from the risk of drug diversion and abuse.
Check Out These Added Benefits
Preventing drug diversion is a worthy cause, not only because it protects your facility from theft, but also because it can let you identify employees who are in trouble and in need of help for their addictions or other problems that lead to diversion. On top of those benefits, automated medication dispensing systems can help with compliance and efficiency, which in turn helps to justify capital investment in the technology.
Inventory control. It's not just about preventing diversion. Auto-mated cabinet systems collect data that you can use to make sure you're maximizing your dollars spent on medication inventory. For example, about once every 3 months I'll go into our system and run a report to detect patterns of usage. If we find a drug that hasn't been used in 3 months, we'll take it out of the system and replace it with something we use more often in order to maximize the use of the cabinet.
Accurate storage. Our cabinets are also equipped with a barcoding system that ensures the correct drug is being placed in the correct location in the drawer when the cabinet is being stocked. Then, when the nurse goes to access that drug, the correct medication will always be dispensed from the correct location.
Outdates monitoring. Check-ing for outdated drugs and upcoming expiration dates is one of the most tedious tasks we have to do in a facility where we store about 4,000 or more individual drug products. Our automatic dispensing system lets us run reports tracking expiration dates and ensures that we discard outdated medications at the appropriate time.
Safety. When a nurse goes into the system and pulls up a drug order, the screen will often prompt her to answer a few questions. These questions are tailored to the particular drug and typically have to do with safety concerns. For example, the system may ask the nurse to verify the name of the drug because there are look-alike/sound-alike medications that can cause confusion. Or it may ask the nurse if she understands that promethazine should never be given intravenously, or that hydromorphone is 7 times more potent than morphine. These automated warnings can help keep even the most seasoned practitioner on her toes and prevent mediation errors.
Richard Carvotta, RPh, MBA