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Pharmacy Leaders Consider Documentation Accuracy a Top Priority but Spend Minimal Resources on Oversight

Each year, Kit Check surveys pharmacy leaders across the country about the challenges they face and best practices employed for controlled substances. Our annual Anesthesia Medication Tracking Survey tracks technology adoption, policy changes, and worries in and around the OR. This year, we asked respondents the simple open-ended question, “What is your biggest challenge in and around the OR?”

Audit by Nick Youngson CC BY-SA 3.0 Alpha Stock Images

Physical control of drugs, charge capture, and accurate documentation are the top issues

The answers were surprisingly consistent and centered on three themes: physical controls/tracking of medications, charge capture and accuracy, and identifying discrepancies/ensuring accurate documentation. Two of these challenges are compounded by the reality that systems of record don’t easily or often talk to each other. Documentation (whether on paper or via an AIMS) and dispenses (whether from kits or cabinets) live in silos and, while reporting out of those systems is readily available, those exports are the starting point for ensuring that documentation is complete, accurate, and thorough.

Closing gaps in the controlled substance record is not only good practice but a fundamental component of remaining compliant with the Controlled Substance Act (CSA). A recent DEA investigation found a major IDN liable for incomplete recordkeeping regarding the shipment, receipt, and distribution of controlled substances through its pharmacies. Diversion can occur at any point along the distribution chain from purchase to patient and pharmacies are ultimately accountable for the complete paper trail of CS in their facility.

Despite being a top concern, documentation oversight is under-resourced at most hospitals

Even given these concerns, 62% of respondents to the Anesthesia Medication Tracking Survey indicated their pharmacy teams are spending less than 5 hours each week identifying discrepancies and closing gaps in their OR controlled substance recordkeeping.

Given the resource limitations and many competing patient-centric duties for pharmacy teams, it is not surprising that the time dedicated to auditing controlled substance records, even just for the OR, is so low. With higher order, patient care-focused activities taking precedence, the ability to audit even a statistical majority of cases is unlikely. Without that coverage, though, the likelihood of detecting anomalous behavior patterns, actual diversion events, or recouping lost charges is nearly zero.

Comprehensive audits avoid issues in the long run

So why spend resources on a comprehensive audit process? Simple: peace of mind.

  • Confidently stand up to questions from external auditors, the DEA, or internal investigations. Rest assured that gaps in controlled substance record keeping have been closed and your team can fully account for all medications as they move from safe to cabinet to patient.
  • Ensure that pharmacy’s role in protecting patient safety extends to controlled substance documentation. Without the level of detail in a 100% audit, patterns of abuse, mis-documentation, waste buddies or other warning signs will likely go undetected.
  • Minimize the costs associated with human resources investigations and, in the event of a diversion event or abuse pattern, the processes associated with termination, recruitment and onboarding to replace a CRNA, Anesthesiologist, Registered Nurse or other staff member. A proactive, comprehensive audit can help identify individuals who would benefit from early intervention and support structures.

For more information about Kit Check’s approach to controlled substance auditing and compliance, contact Hannah Byam at