Implementing Systems for Detection and p g y fPrevention of Drug Diversion

Mitch Sobel RPh Assistant Director of Pharmacy ServicesMitch Sobel, RPh, Assistant Director of Pharmacy ServicesSaint Barnabas Medical Center, Livingston, New Jersey

Aline Greene, RN, CEN, Pyxis Nurse LiaisonRoper Saint Francis Healthcare Charleston South CarolinaRoper Saint Francis Healthcare, Charleston, South Carolina

Elaine Jones, RPh, MBA, Director of Regulatory Compliance Cardinal Health Pharmacy Management

Friday, January 27, 2006

Drug Diversion Happens at Hospitals It’s a FACTHospitals - It’s a FACT By nurses By nurses By pharmacists By physicians By physicians By unlicensed staff By other licensed professionals By other licensed professionals By visitors/general public

How Big of a Problem is Drug Diversion?Diversion? 6-15% nurses abuse drugs found in hospitals 6 15% nurses abuse drugs found in hospitals

Indiana Board of Nursing 12 anesthesiologists die from overdoses of 12 anesthesiologists die from overdoses of

fentanyl a year; abuse drugs 3x the general physician population American Society of Anesthesiologists

Top Rx Drugs of AbuseTop Rx Drugs of AbuseHydrocodone (Vicodin, Lortab, Lorcet) $6 - $8

Oxycodone (Oxycontin)(Percocet Percodan Tylox)

$.50 - $1/mg$6 - $10(Percocet, Percodan, Tylox) $6 $10

Acetaminophen (Tylenol #3 Tylenol #4) $3 $5Acetaminophen w/codeine

(Tylenol #3, Tylenol #4) $3 - $5

Diazepam (Valium) $1 - $2p ( )

Propoxyphene (Darvon, Darvocet) $2 - $4

Top Rx Drugs of AbuseTop Rx Drugs of AbuseCarisoprodal (Soma) $3 - $4

Morphine (MS Contin) 100mg - $60 / 60mg -$45

Alprazolam (Xanax) $3 - $5

Meperidine (Demerol®) N/A (H/P usage)

Methylphenidate (Ritalin) $10 - $15

Hydromorphone (Dilaudid®) 4mg $60Hydromorphone (Dilaudid®) 4mg - $60

Fentanyl (Sublimaze) $35

Other Significant ProblemsOther Significant Problems Stadol Nasal Spray Proventil Ultram Phenergan Phenergan Codeine containing cough syrup Methadone Ketamine High Expense Drugs: Neupogen, Epogen, Growth

Hormone Life Style Drugs: Viagra, Propecia, Nolvadex

Warning SignsWarning Signs

Staff members seeing changes in co workers

Warning SignsWarning Signs

Staff members seeing changes in co-workers behavior

Employee asking to witness excessive wastage

Continuous issues with inventory managementContinuous issues with inventory management

Employee Warning SignsEmployee Warning Signs

Deteriorating job performance. Psychological changes. Psychological changes. Behavioral changes. Changes in physical appearance Changes in physical appearance. Length of addiction may result in

employees showing no signs at all.employees showing no signs at all.

Methods of EnablingMethods of Enabling Failure to recognize warning signs.g g g Attributing signs to other causes (stress,

illness, etc.). Provides coworker with password. Co-signing wastage not observed.g g g Making excuses for person not following

narcotic handling procedures.

Common DenominatorsCommon Denominators

Employees on medical leave: Employees on medical leave: Post-surgery Post-injuryPost injury

Other factors:Other factors: Stress Family issuesy History

Typical Nurse ProfileTypical Nurse Profile

Best nurse on the floor Never would have

suspected him/her Willing to work extra

shifts Stays late after shift Stays late after shift

ends Comes in early for shift

Typical Nurse ProfileTypical Nurse Profile

Agency/Registry nurse Agency/Registry nurse

Divorce/child custody Divorce/child custody

Recent health problem Recent health problem

Death/illness in family Death/illness in family

Typical Nurse ProfileTypical Nurse Profile

May show up on off days May show up on off days

Prefers night shift Prefers night shift

Prefers high narcotics floors Prefers high narcotics floors

Signs out more narcotics than peers Signs out more narcotics than peers

Typical Nurse ProfileTypical Nurse Profile

Frequently documenting waste Frequently documenting waste

Nursing notes do not coincide with drugs Nursing notes do not coincide with drugs given

Frequent restroom breaks

Typical Nurse ProfileTypical Nurse Profile Using drugs on the jobg g j

Record keeping becomes sloppy

Impaired or passed out at work place

Patient complaints

Co-worker complaints

Typical Nurse ProfileTypical Nurse Profile

Using Schedule II injectables Using Schedule II injectables (Demerol®, Morphine, Dilaudid®)

Self addicted

Not trafficking

Pharmacy Nurse Liaison Positiony

Work closely with pharmacy and nursing with any y p y g yissues related to medication administration.

Review the Standard Deviation Reports for possible offenders – and send reports to managers for reviewoffenders and send reports to managers for review

Report the every other month narcotic chart audit for the nurse managersC l t i d th i if d d i j ti Complete in-depth review if needed in conjunction with Director of Nursing and Director of Pharmacy

Random Narcotic Chart ReviewReview

Overall Compliance with Narcotic DocumentationJan-05 Mar-05 May-05 Jul-05

Waste Doc 88% 97% 97% 100%Waste Doc 88% 97% 97% 100%Effect. Doc 80% 72% 75% 68%

88% 97% 100%80% 72% 68%

40%

60%

80%

100%

Overall Compliance w ith Narcotic Documentation

Waste Documented Jan-05 Mar-05 May-05 Jul-05

2nd Center 100% 100% 100% 100%ER 100% 100% 100% 100%

0%

20%

Waste Doc Effect. Doc

ER 100% 100% 100% 100%CICU 100% 100% 100% 100%NICU 60% 100% 100% 100% CONGRATULATIONS!!!!!!!

LDRP 83% 100% 100% 100%4 Med Surg 50% 100% 100% 100%

BMU 100% 100% 100% 100%TELE 100% 100% 100% 100%

1 Med Surg 100% 75% 88% 100%

Effectiveness Documented Jan-05 Mar-05 May-05 Jul-052nd Center 67% 100% 100% 91%

ER 100% 86% 94% 100%CICU 76% 67% 89% 67%NICU 61% 83% 72% 67% We Have Work to do!

LDRP 56% 6% 22% 24%4 Med Surg 100% 44% 72% 28%

BMU 100% 100% 100% 100%TELE 83% 22% 78% 78%

1 Med Surg 81% 66% 53% 61%

Diversion PreventionDiversion Prevention

Culture of responsibility – interdisciplinary Culture of responsibility interdisciplinary team of pharmacists, nurses, physicians and corporate security officers.

Delineation of tasks and responsibilities. Accountability on all levels of the process.y p Securing purchases and wastes. Utilization of technology – closed electronic Ut at o o tec o ogy c osed e ect o c

loop.

Section 1301.71 Security Requirements G llGenerally

(a) All applicants and registrants shall provide effective controls and procedures to guard against theft and diversion of controlled substances.

Reports and Data Interpretation

Controlled Substances Vault Access Report.

All E t R t All Events Report.

Controlled Substances Vault Compare Report.

Review Send Report.Report Title Documentation (Discrepancy Y or N, If Y then detail) Initials

Automated Dispensing Machine (ADM) Report.

Purchase History Report.

Proactive Controlled Substances Diversion Report.

p ( p y , )CII Safe Pyxis Compare (covers 24hr period, run Bi-monthly)

N Y

Proactive Diversion Report (covers week period, run monthly)

N Y

All Station Events for Nurse Managers (covers 72hr period, run Bi-monthly)

N Y

Open Discrepancies (available on console screen)

See Controlled Substances Discrepancy Log

Documented (i.e. Resolved) Discrepancies (covers 24hr period, run Bi-monthly)

N Y

Waste and Return (covers 24hr period, run Bi-monthly)

N Y

Overrides (covers 24hr period, run Bi-monthly)

N Y

Documented Discrepancies Report.

Waste and Return Report.

Overrides Report.

All Station Events Patient Chart Review (run monthly)

N Y

Inventory Verification Report (all units, 1 rotating item, run monthly)

N Y

OCCURRENCE

REPORT RECEIVED

DATE

OF EVENT

TIME OF EVENT

PATIENT

CARE AREA

DESCRIPTION OF DISCREPANCY

RPH

YES NO

p

Inventory Verification Report.

All Station Events for Nurse Managers (Consultant).

DISCREPANCY RESOLUTION

OCCURRENCE REPORT RECEIVED

DATE

OF EVENT

TIME OF EVENT

PATIENT

CARE AREA

DESCRIPTION OF DISCREPANCY

RPH

YES NO

DISCREPANCY RESOLUTION

Open/Unresolved Discrepancies (Console Screen).

Standard Deviation Report (>3) Standard Deviation Report (>3) ––listed by employee / by Monthlisted by employee / by Month

Standard Deviation Report (>3) -- listed by employee / by Monthtotal #

deviationstotal #

deviationsEmployee Name

deviations 2004 2004

deviations 2005 2005

Alice P., RN 1 09/04 3SL3 Aline H., RN 1 09/05 3SLAmy B., RN 1 3/04 3SL1

02/05 3SL2

Beverly W., RN 1 09/04 3SL1 308/05 3SL1 10/05 3SL2

Brian K., RN 1 06/05 ER

Carol M., RN 211/04 PCU 12/04 PCU 1 1/05 PCU

Casey G RN 1 1/05 3SLCasey G., RN 1 1/05 3SL

Catherine R., RN 1 08/04 SPCU 203/05 SPCU 10/05 SPCU

Colleen A., RN 1 07/05 PCU

Darby G., RN 107/04 PCU1 08/04 PCU1 1 02/05 PCU

Dean O., RN Terminated 4

04/05 1M 05/05 1M 06/05 LDRP 07/05 SPCU

Diana X., RN 1 07/04 LDRP 1 08/05 LDRPDiane K RN 1 2/04 4SV2 1 05/05 PCUDiane K., RN 1 2/04 4SV2 1 05/05 PCUDiane P., RN 1 04/05 ICUDonna S., RN 1 07/05 LDRP

Specific Nurse Review Specific Nurse Review ------ Removals & WastageRemovals & Wastage

User Name Pt ID Pt NameTransaction

TimeTransaction

Type Medication Description QtyWitness Name TextUser Name Pt ID Pt Name Time Type Medication Description Qty Name Text

NURSE,NAN 10006 BARB 08/06/05 00:45 Removed MORPHINE SUL 2 mg/1 ml INJ 1.NURSE,NAN 10006 BARB 08/06/05 03:31 Removed MORPHINE SUL 2 mg/1 ml INJ 3.NURSE,NAN 10006 BARB 08/06/05 06:19 Removed MORPHINE SUL 2 mg/1 ml INJ 3.NURSE,NAN 10006 BARB 08/06/05 20:35 Removed MORPHINE SUL 2 mg/1 ml INJ 3.NURSE,NAN 10006 BARB 08/06/05 23:30 Removed MORPHINE SUL 2 mg/1 ml INJ 3.NURSE,NAN 10006 BARB 08/07/05 04:20 Removed MORPHINE SUL 2 mg/1 ml INJ 3.NURSE,NAN 10006 BARB 08/07/05 20:58 Removed MORPHINE SUL 2 mg/1 ml INJ 3.NURSE NAN 10006 BARB 08/07/05 22:42 Removed MORPHINE SUL 2 mg/1 ml INJ 3NURSE,NAN 10006 BARB 08/07/05 22:42 Removed MORPHINE SUL 2 mg/1 ml INJ 3.NURSE,NAN 10006 BARB 08/08/05 04:35 Removed MORPHINE SUL 2 mg/1 ml INJ 3.NURSE,NAN 10256 KEVIN 08/06/05 23:16 Removed meperidine hcl 50 mg/1 ml syringe 1.NURSE,NAN 10256 KEVIN 08/07/05 03:13 Removed meperidine hcl 50 mg/1 ml syringe 1.NURSE,NAN 10256 KEVIN 08/07/05 07:21 Removed meperidine hcl 50 mg/1 ml syringe 1.NURSE,NAN 10256 KEVIN 08/07/05 22:40 Removed meperidine hcl 50 mg/1 ml syringe 1.NURSE,NAN 10256 KEVIN 08/08/05 01:27 Removed oxycodone-apap 5/325 tablet 2.NURSE,NAN 10256 KEVIN 08/08/05 03:06 Removed meperidine hcl 50 mg/1 ml syringe 1.NURSE NAN 10018 AMY 08/20/05 20:14 Removed HYDROMORPHONE HCL 2 mg/1 ml INJ 2 NATHAN AMT GIVEN: 3 mg (AMT WASTED: 1 mg)NURSE,NAN 10018 AMY 08/20/05 20:14 Removed HYDROMORPHONE HCL 2 mg/1 ml INJ 2. NATHAN AMT GIVEN: 3 mg (AMT WASTED: 1 mg)NURSE,NAN 10018 AMY 08/20/05 20:14 Removed LORAZEPAM 2 mg/1 ml vial 1. NATHAN AMT GIVEN: 1 mg (AMT WASTED: 1 mg)NURSE,NAN 10018 AMY 08/20/05 22:37 Removed morphine sulfate pca 30 mg/30 ml vial 1.NURSE,NAN 10018 AMY 08/20/05 23:24 Removed HYDROMORPHONE HCL 2 mg/1 ml INJ 2. NATHAN AMT GIVEN: 3 mg (AMT WASTED: 1 mg)NURSE,NAN 10018 AMY 08/21/05 02:11 Removed LORAZEPAM 2 mg/1 ml vial 1. ALINE AMT GIVEN: 1 mg (AMT WASTED: 1 mg)NURSE,NAN 10018 AMY 08/21/05 21:16 Removed LORAZEPAM 2 mg/1 ml vial 1.NURSE,NAN 10018 AMY 08/21/05 22:30 Removed HYDROMORPHONE HCL 2 mg/1 ml INJ 2.NURSE,NAN 10018 AMY 08/21/05 23:22 Removed morphine sulfate pca 30 mg/30 ml vial 1.NURSE NAN 10018 AMY 08/21/05 23:26 Wasted from Station HYDROMORPHONE HCL 2 mg/1 ml INJ NATHAN AMT GIVEN: 0 mg (AMT WASTED: 4 mg)NURSE,NAN 10018 AMY 08/21/05 23:26 Wasted from Station HYDROMORPHONE HCL 2 mg/1 ml INJ NATHAN AMT GIVEN: 0 mg (AMT WASTED: 4 mg)NURSE,NAN 10018 AMY 08/22/05 01:39 Removed HYDROMORPHONE HCL 2 mg/1 ml INJ 2. ALINE AMT GIVEN: 3 mg (AMT WASTED: 1 mg)NURSE,NAN 10018 AMY 08/22/05 02:17 Removed LORAZEPAM 2 mg/1 ml vial 1. ALINE AMT GIVEN: 1 mg (AMT WASTED: 1 mg)NURSE,NAN 10018 AMY 08/22/05 04:48 Removed HYDROMORPHONE HCL 2 mg/1 ml INJ 2. ALINE AMT GIVEN: 3 mg (AMT WASTED: 1 mg)NURSE,NAN 12547 MARIE 08/27/05 02:33 Removed MORPHINE SUL 2 mg/1 ml INJ 3.NURSE,NAN 12547 MARIE 08/27/05 04:18 Removed MORPHINE SUL 2 mg/1 ml INJ 1.NURSE,NAN 12547 MARIE 08/27/05 04:59 Removed MORPHINE SUL 2 mg/1 ml INJ 2.NURSE,NAN 12547 MARIE 08/27/05 06:39 Removed hydrocodone-apap 5/500 tablet 3.NURSE NAN 12547 MARIE 08/27/05 21:10 Removed MORPHINE SUL 2 mg/1 ml INJ 3NURSE,NAN 12547 MARIE 08/27/05 21:10 Removed MORPHINE SUL 2 mg/1 ml INJ 3.NURSE,NAN 12547 MARIE 08/27/05 22:20 Removed hydrocodone-apap 5/500 tablet 3.NURSE,NAN 12547 MARIE 08/27/05 23:22 Removed MORPHINE SUL 2 mg/1 ml INJ 3.

Diversion StoriesDiversion Stories Removing other meds (Benadryl®, Vistaril®, Phenergan®)

i i i IV i d f h igiving it IV instead of the narcotic Putting the narcotics in a towel in the ceiling of the lounge, found

when water line broke R i ll d h fi t d t Removing all meds when nurse first comes on duty – even

before patient asks for pain medications Nurse saying they just threw the pill away and asked co-worker

to sign waste --- ‘trust factor’ between the staffto sign waste trust factor between the staff With range order meds (1-2tabs; 25-50mg) – taking full dose out

½ to patient other ½ of dose to themselves If not using automated machines, it is very easy for a full sheetIf not using automated machines, it is very easy for a full sheet

of narcotic to walk away and not be found out by pharmacy for months

Needle thru top of PCA syringe and saline put in place

Narcotic Diversion Schemes

Narcotic pull for excessive amounts of patientspatients.

Pull larger dose than patient receives.

Remove drug from IV drips.

Pattern of broken vials and ampoules Excessiveampoules. Excessive “accidents”. Check rubber stoppers for punctures.

Vial breakage is clean. Vials are sheared without fragments.

Intact narcotics thrown in Intact narcotics thrown in general trash.

Narcotic Diversion Schemes continued…

Pulverized or broken tablets. Pieces of tablet or powder of capsule missing. p p g

Substituting diluent for active injectable narcotic in IV bags.

Substituting look alike legend drug tablets for Substituting look alike legend drug tablets for active narcotic tablets (Bingo cards, blister packs).

Heated needle through bottom of glass l IV bampoule or IV bag.

Curved needle used to go between metal lid and rubber stopper on vials.

Users are created and deleted in a short period of time. Upon review, users are fictitious.

Employees work and make transactions during off-shifts or unscheduled times.