Ensure education for recognizing/reporting suspicious behaviors
Reprinted with permission from New Perspectives, Journal of the Association of Healthcare Internal Auditors, Inc. Volume 41/Number 5.
By Jennifer Splawski, PharmD, MS, BCPS
Controlled substance medication diversion is on the rise in healthcare. Reports indicate that diversion costs the healthcare industry more than $70 billion per year, and up to 10 percent of healthcare providers will divert drugs at some point in their career. But provider personnel do not receive adequate training to be diversion preventionists or police. Do your personnel know what to do if they suspect diversion at your facility?
Often management and staff are unaware of the actions to take when diversion is suspected and reported. When surveyed, 50 percent of hospital respondents reported that they did not have a procedure, or did not know, what they would do when they identified a possible diverter.
Provider personnel commonly believe that diversion would not happen in their unit due to close working relationships and trust among colleagues. Individuals may also be unable to recognize signs and symptoms of drug diversion or drug abuse. Someone diverting medications may put off inquiries by saying their behavior is due to being stressed, having a bad day, or being burned out and tired.
One of the barriers that may exist in reporting is a fear of reporting on a colleague. Fear of retaliation for reporting diversion suspicions from staff members or management can be a barrier. Feeling apprehensive when reporting a superior is understandable, such as when a certified registered nurse anesthetist reports an anesthesiologist, or a pharmacy technician reports a pharmacist.
A potential reporter of diversion may be worried about being a part of a lawsuit or a diversion case that could affect the reporter’s professional license. Despite the fears, everyone should know that reporting can potentially save a patient’s or even an employee’s life.
You need to be prepared to answer common questions regarding drug diversion and recommend tools for frontline line healthcare providers to understand, identify and report behaviors that may affect patient and employee safety. The DEA recognizes five classes of drugs that are frequently misused—anabolic steroids, central nervous system depressants, hallucinogens, opioids and stimulants. The medications can be diverted for use in recreational purposes, relief of addiction or withdrawal, monetary gain, self-medication for pain, anxiety or sleep.
Consequences of diversion
Diverters − Drug diversion has consequences that can affect everyone from the patient to the entire health system. Individuals who are diverting medications can be subject to civil or criminal penalties. They could possibly forfeit licensure, suffer career damage, or die. In addition, if diverters survive an overdose, they could suffer an anoxic brain injury or acquire an infection from an unsanitary injection.
Coworkers − The coworkers of diverters can suffer consequences from diversion schemes. Coworkers may unknowingly aid diversion by witnessing fake wasting or disposal by coworkers who are diverting medications. Coworkers can also risk physical harm if the diverters leave
contaminated needles or broken vials in nursing units and other patient care areas.
Organizations − The individual’s employer and health system also suffer the consequences of diversion. Employers can be affected by a loss of revenue from missing medications ,increased employee absenteeism, and increased resources devoted to investigation and testing. Regulators can impose large fines and drug diversion lawsuits can result in substantial monetary settlements. One health system paid $7.75 million to the DEA to settle allegations of inappropriate pharmacy operations that included diversion.
Patients − Patients are the parties most affected by drug diversion. The healthcare provider’s oath is to “do no harm.” When patients are being treated by individuals who are diverting medications, they very possibly receive substandard care. Patients may not get appropriate pain medication after a procedure, or they may be infected by a contaminated or adulterated drug. They can become sicker than when they came into the hospital.
Drug diversion has a large effect across the healthcare industry. Reporting of any potential drug diversion is extremely important. An anonymous report can save lives and avoid other serious consequences.
TJC – Quick Safety Issue 48: Drug Diversion and Impaired Health Care Workers (https://www.jointcommission.org/resources/newsandmultimedia/newsletters/newsletters/quick-safety/quick-safety-48-drug-diversion-andimpairedhealth-care-workers/)
• What Is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs? (https://www.cms.gov/files/document/prescriberroledrugdiversion033115pdf#:~:text=Drug%20diversion%20is%20the%20illegal,and%20ultimately%20to%20the%20patient)
• A Nurse Manager’s Guide to Substance Use Disorder in Nursing (https://www.ncsbn.org/3692.htm)
• Signs and Behaviors of Impaired Colleagues (https://www.aana.com/practice/health-and-wellness-peer-assistance/About-AANA-Peer-Assistance/substanceuse-disorder-workplace-resources/signs-andbehavior-of-impaired-colleagues)
Signs of impairment, substance misuse and diversion
Staff cannot always easily recognize changes in colleagues’ behavior regarding substance misuse or drug diversion. When a colleague looks to be impaired, they are not necessarily diverting medications. If a colleague is diverting medications, they are not necessarily impaired.
Diversion-related changes in behavior can be subtle and hard to differentiate from normal stress-related behaviors and substance misuse. Exhibit 1 provides a reference on how a colleague can change if they struggle with substance abuse. The summary is not inclusive of all possible attributable behaviors. Staff need to be reminded that if they see something, they should say something. Failing to report a concern can harm patients or place a colleague’s life at risk.
Steps to promote a culture of safety with reporting
Implement policies and procedures
Promoting a culture of safety is key to diversion prevention. All hospital employees, not just direct patient caregivers, need to be educated about diversion and what to do if they identify a potential or risk for diversion. For example, what if a housekeeping employee finds a half-used vial of a controlled substance in a breakroom while they are cleaning?
Each employee type should have training customized to how their work can be affected by drug diversion, and should have the tools to report incidents. Policies should be readily available for employees to reference, updated routinely, and include a minimum annual education expectation regarding policy refreshers and updates. When healthcare workers understand why policies and procedures exist and buy into a culture of safety, diversion can be detected earlier and have better outcomes.
Establish reporting mechanisms
The DEA takes the position that employees have the responsibility to report knowledge of drug diversion to their employer because drug diversion can pose a substantial public health risk and should be taken seriously. Your organization should keep reports confidential and take reasonable steps to maintain the confidentiality of the individual who reports suspected diversion.
Your organization should encourage reporting from all staff members. Employees should not fear reporting or suffer retaliation. Your organization should have methods for reporting suspected diversion, such as a confidential hotline, email address and/or an online reporting portal. Ensure that your employees are educated about how and where to report these events. Educate your employees to report
these events through dedicated channels or to security or management, and to never confront the suspected employee on their own.
Provide resources for employees with needs
Provide resources and care for employees suffering from substance use disorder. Healthcare organizations should offer employees treatment instead of termination. Facilitating treatment for impaired employees is more cost effective than replacing them.
Healthcare workers may be reluctant to admit they have a problem due to stigma and fear of losing their job or license. According to the National Council of State Boards of Nursing, many states offer treatment and rehabilitation programs instead of disciplinary action. The programs will remove a nurse from patient care until recovery has been completed and they are safe to return to practice. Upon returning to practice, the individual and the employer should then decide if the individual should return to work in his/her previous scope or should no longer handle controlled substances.
Organizations should recognize the employee’s right to be accommodated when they have a diagnosed substance use disorder. Recognition does not mean a preferred or ideal accommodation, but one that works for both the employee and the employer. Resources are listed in Exhibit 2 for substance use disorder treatment and recovery.
Exhibit 2 – Resources for substance use disorder treatment and recovery
• Seeking Drug Abuse Treatment: Know What to Ask (https://nida.nih.gov/sites/default/files/treatmentbrochure_web.pdf)
• SAMHSA’s National Helpline is a free, confidential, 24/7, 365 days a year treatment referral and information service, call 800-662-4357
• National Suicide Prevention Lifeline, 24/7,365 days a year, call 800-273-8255 (https://suicidepreventionlifeline.org/)
Healthcare providers have easy access to prescription medications and diversion of these medications can lead to severe patient harm. You can provide answers to commonly asked questions about diversion, ensure that sound policies and procedures exist and verify that education has been provided.
Healthcare providers must feel empowered to say something if they see something. Speaking up could save a patient or colleague’s life. Everyone is responsible to make sure patients and colleagues are free from harm.
Jennifer Splawski, PharmD, MS, BCPS, is a Director of Clinical Solutions at BluesightⓇ . She has developed and trained pharmacy and nursing staff, as well as physician users on auditing, analytics and best practices in diversion monitoring. Jennifer can be reached at Jennifer.Splawski@kitcheck.com.