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Increasing scrutiny for hospital pharmacies over management and use of controlled substance inventory

By Weiss Paarz CC BY-SA 2.0

As the opioid epidemic continues to make headlines, hospitals are facing increasing pressure to detect and prevent controlled substance diversion. In response, the American Society of Health-System Pharmacists (ASHP) released guidelines on developing a comprehensive diversion prevention program which builds upon similar publications by the CDC, DEA and The Joint Commission. Given the risks, hospitals should heed these guidelines to ensure they have the safeguards in place to avoid similar incidents that have plagued the headlines.

ASHP guidelines on preventing diversion of controlled substances

[su_pullquote align=”right”]1 million
doses diverted by 2 pharmacy techs[/su_pullquote]

The primary recommendation of the ASHP Guidelines is to create a multi-disciplinary task force. By including representatives from administration, pharmacy, information technology and provider groups, a collaborative program promotes a culture of accountability and is able to drive hospital-wide improvements. The diversion prevention task force is responsible for staying up-to-date on regulatory requirements, reviewing and improving policies and procedures, and ensuring there are adequate system-level and provider-level controls in place. This oversight should include everything from storage and security, to prescribing and medication dispensing practice, to staff education and real-time response to incidents.

Organizational challenges facing hospital pharmacies

[su_pullquote align=”left”]1 in 10
practitioners fall into drug or alcohol abuse[/su_pullquote]

Cultural challenges can stand in the way of fostering a culture of accountability and compliance. Many hospitals have legacy practices that prioritize physician satisfaction over a potentially more secure system of controls, what diversion expert Greg Burger calls a “culture of cater.” Similarly, a “culture of trust” is often the basis for diversion prevention strategies, rather than a sophisticated system of controls, checks, and processes that apply regardless of the employee’s position, seniority or convenience. While trust is a crucial component in team-based care, lax or non-compliant practices can easily be perpetuated when allowances are made for individual employees.

Creating a culture of compliance

[su_pullquote align=”right”]$5.6 million

street value of oxycodone doses diverted by DOP[/su_pullquote]

So how to create a “culture of compliance” around controlled substances with the same emphasis and internal support that meets accreditation surveys/visits and other patient-care standards? Directors of Pharmacy must balance headcount, budgets, clinical duties and core pharmacy work. 100% manual audit coverage isn’t a reality for most pharmacies given the staff numbers and budgets of today, but we’ve identified three steps to take toward greater audit coverage and controlled substance visibility:

  • Aggregate data across systems
  • Use machine learning to facilitate workflows
  • Leverage data to facilitate conversations on how to improve

The costs of drug diversion are simply too high for hospitals to make the tracking, monitoring, and auditing of controlled substances anything other than a top priority. Contact me ( if you are interested in learning more about how Kit Check is helping augment hospital pharmacies’ efforts to prevent diversion.