CONTROLLED SUBSTANCES Limit access to medications, and monitor their use and disposal.

Let me guess: Drug diversion can never happen on your watch because no one on your all-star staff has a substance abuse problem. Maybe so, but don't you think administrators at facilities where drug diversion actually happened once thought the same thing? Take a few minutes to ensure these 5 drug security precautions are in place, even if you think you have nothing to worry about.

4-3-2-1 Secure anesthesia workrooms or drug storage cabinets with a combination lock.

Locked storage?
You must keep controlled substances in locked cabinets or secured storage areas. Using employee-specific swipe cards is a great way to limit access to controlled substances. You can program the system to allow access only to certain employees, and monitor exactly who swiped in and when. Combination locks are a less costly but still effective option for securing anesthesia workrooms or drug storage cabinets. You need to have a written policy in place that stipulates who on the staff can know the lock's combination and how often it should be changed.

It's a good idea to change the combination periodically. One accreditation surveyor told me that he's seen staff members write lock combinations in pencil on a doorsill or a nearby wall. Another surveyor told me that he was able to access a medication storage area because the combination's numbers on the keypad lock were worn from frequent use. Then there's always the possibility that a manager with approved access to controlled substances absentmindedly shares the combination with a staff member. Changing a lock's combination a few times a year will help limit the risks of these potential security breaches.

Daily counts?
Two staff members must perform daily counts to ensure all controlled medications are accounted for. One nurse performs the actual count of vials in storage, stating the drug name and quantity, and the second nurse confirms that the day's count coincides with the perpetual count.

Staff members should conduct counts of controlled substances first thing in the morning and at day's end, but do they perform them with the needed focus each time? Staff are understandably busy in the morning preparing the facility for cases and they're likely anxious to tie up loose ends and head home at the end of the day. Narcotic counts, because they're often the same each day, might be where they cut corners. But haphazard inventory checks will eventually lead to trouble. I've heard nurses say they've assumed all vials of a rarely used drug are present and skip the actual count, only to find out one's been missing for who knows how long.

Limited access?
Policies for controlling access to controlled substances will differ from facility to facility. I'm often asked if contracted anesthesia providers should have access. Individual facilities must make that call, but in my opinion, anesthetists shouldn't have access. RNs involved with drug distribution and department managers should maintain regular control of medication storage and counts. Perhaps you can set up a system of individual storage bins with breakaway seals so contracted anesthesia providers can get the medications they need for a day's cases.

Regular audits?
You must have checks and audits in place for the handling of controlled substances, from when they enter your building to when they're administered to patients. Keeping tabs on controlled substances can't be limited to occasional audits by a consulting pharmacist; nurse managers must have a role in auditing the drug management process.

Conduct regular chart audits to compare what's been administered to what's been signed out. Even if you don't notice questionable drug management, your staff will notice that someone is auditing the process. Anyone who's considering diverting drugs would have to think twice if they're not entirely sure of who's checking what and when. Simply completing audits in plain view puts doubt in the mind of a would-be stealer. Can I get away with this? Maybe not.

You can also use audits to look for drug administration trends that might reveal red flags that warrant further investigation. Are dosing amounts written over? (To make a correction, strike a line through the number and rewrite the correct figure.) Is documentation sloppy? Are signatures missing next to count or wastage records? How often do nurses sign out narcotics and how much medication wastage do they dispose of at the end of the day? How many narcotic administrations do they handle compared to colleagues on the same shift? Are they disposing of wastage immediately?

Constant vigilance?
Properly performed manual audits eliminate a great deal of drug diversion risk for your facility, but can't end it entirely. Medication can still be swiped from the sterile field or a nurse might divert a small amount of painkiller from a filled syringe. It's nearly impossible to catch those types of thefts. The best you can do is put up as many barriers as possible.

In the wrong hands, all drugs, not just narcotics, can do significant harm to patients and other individuals. You and your clinical managers can't observe all that goes on in your facility on a daily basis, so every staff member has a responsibility to ensure patient safety, and medication security is a big part of that obligation. They also have legal and ethical responsibilities to report anyone who's acting suspicious or whose behavior has changed noticeably. It's better to point out suspicions of abuse than run the risk of letting abusers jeopardize their own well-being and the safety of the patients in their care.