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What Does ASHP’s Revised Drug Diversion Guidelines Mean for Your Hospital?

What Does ASHP’s Revised Drug Diversion Guidelines Mean for Your Hospital?

By: Sandy Still, PharmD


The American Society of Health System Pharmacists (ASHP) released revised guidelines on preventing diversion of controlled substances. ASHP serves as an industry leader and voice for pharmacists with over 60,000 members across the United States. This is the first revision to the guidelines since its initial publication in 2016. 


The update to these guidelines show that controlled substance diversion is still an issue that is top of mind. For health systems without a drug diversion prevention program, these updated guidelines can be leveraged with members of their C-suite to emphasize the importance of developing a comprehensive program. For health systems that already have a program in place, this provides an opportunity to revisit existing programs, identify gaps and make potential improvements.


The guidelines recommend identifying high-risk areas including surgery, anesthesia, sterile compounding areas, the controlled substance vault, and emergency departments to avoid blind spots. Hospitals may also consider tracking non-controlled substances that pose a high-risk for diversion such as propofol, gabapentin and insulin. 


Some of the key takeaways were the importance of creating a culture of safety within the health system, preventing diversion in ambulatory settings and a new emphasis on technology. Below we discuss why these topics are vital for health systems and their drug diversion prevention programs.


Culture of Safety

The revised ASHP guidelines highlight the importance of creating a culture of safety through education on all aspects of diversion awareness.


It is recommended all healthcare workers receive an initial orientation and annual education in diversion prevention as well as substance abuse. All staff members should be able to recognize the signs of drug diversion, the behavior patterns of a colleague who may be struggling with a substance use issue, and know how to report their concern. 


Creating a culture of safety comes from the top down. It’s imperative that leadership is engaged in implementing a diversion prevention program, and there is multidisciplinary involvement, including nursing, pharmacy, anesthesia and compliance.


Staff members should have a clear understanding of how to report a case of diversion, what happens during the investigation, and how diversion impacts patients, colleagues, the organization, and the person involved in the incident.


The guidelines emphasize that there should be a process for healthcare workers who may be struggling with substance use issues. Developing a plan to support the recovery of impaired colleagues and healthcare workers is key to a successful culture of safety surrounding diversion prevention. Hospitals can take an active role in supporting their staff by attending this webinar on identifying and supporting and impaired healthcare worker. 


Ambulatory Pharmacy Settings

Controlled substances can be diverted during any stage of the medication lifecycle and can extend past the boundaries of a physical hospital. It’s important that all areas handling controlled substances develop a surveillance and audit process for controlled substances.


Community and mail order pharmacies are vital parts of health systems and can’t be overlooked in a health system’s diversion prevention program. The updated guidelines have a new section detailing the fundamental aspects of controlled substance management to prevent and detect possible diversion in these settings. 


Emphasis on Technology 

When the ASHP guidelines were initially released in 2016, medication surveillance technology was not nearly as advanced as it is today. Technology has become a clear component of a comprehensive drug diversion prevention program. Automated Dispensing Cabinets (ADCs) have become the standard of care and should be used, at a minimum, in high-risk areas. This automation allows for secure storage of medications, visibility into medication use, and safeguards to prevent human error. 


Access to controlled substances within ADCs should be limited to the lowest unit of use to minimize waste.


Maintaining a perpetual inventory of controlled substances is important to identify discrepancies. Many organizations perform inventory counts of controlled substances in ADCs at the end of every shift, daily, or weekly, depending on their internal policies. These guidelines suggest that unless verified by blind count, controlled substances in ADCs can be inventoried once a week, cutting down on potential discrepancies created during inventory counts and improving staff efficiency.


The guidelines stress the importance of being able to reconcile all controlled substance orders against administration records. The sheer volume of records makes this process extremely labor-intensive, therefore the most effective way to achieve this is with technology solutions that provide closed loop reconciliation and surveillance analytics.


To achieve these analytics, the guidelines give recommendations into what key process indicators (KPI) should be used to evaluate risk points in procurement, prescribing, dispensing, administration and waste.


As health systems build out their diversion programs, leveraging the expertise of their vendor partners may be useful to automate data and support diversion programs. Vendors should be able to work collaboratively with health systems to help implement a diversion prevention program as well as engage in staff training and continuous improvement plans. 


“Vendors providing drug diversion monitoring solutions have a critical role in ensuring health systems effectively and successfully use their technology solutions, while hospital feedback and collaboration is vital for the continuous improvement of these solutions” said Kit Check’s Doug Zurawski, PharmD, Vice President of Strategic Accounts. 


As health systems review these guidelines and evaluate their diversion prevention programs, partnering with a diversion solutions vendor can help achieve more visibility and full-range analytics. 


ControlCheck™ can help hospitals stay vigilant and proactive when it comes to diversion. 


ControlCheck has partnered with over 500+ hospitals and helps bring item-level visibility into a hospital’s controlled substance inventory and highlights activity that may pose a risk for diversion, so patients can receive the exemplary care they deserve.