Institutional Policy Manual

Transcription

1 Institutinal Plicy Manual Drug Diversin Reprting and Respnse Cntent Applies t Arizna, Flrida, Rchester Scpe Arizna, Flrida, Rchester Purpse T prvide guidelines fr the identificatin, reprting, and investigatin f suspected drug diversin by May emplyees, patients, and visitrs. Key Terms Drug Diversin: Intentinally and withut prper authrizatin, using r taking pssessin f a prescriptin medicatin r medical gas frm May supplies, May patients, r thrugh the use f May prescriptin, rdering, r dispensing systems. Examples f drug diversin include, but are nt limited t, the fllwing: Medicatin theft Using r taking pssessin f a medicatin withut a valid rder r prescriptin Frging r inapprpriately mdifying a prescriptin Using r taking pssessin f medicatin waste, i.e., left ver medicatin Prescriptin medicatin: A medicatin that accrding t federal law requires a prescriptin prir t dispensing. Synnym: legend medicatin. Emplyee: Any cnsulting staff, administrative staff, allied health staff, fellw, resident, student, vlunteer, cntract wrker, r any ther emplyee r individual wh has received an appintment at May Clinic. Cntrlled substance: Medicatins classified as Schedule I thrugh V by the Federal Drug Enfrcement Agency and/r applicable state law: Arizna: Arizna Revised Statutes thrugh 2516 Flrida: Flrida Statutes Rchester: Minnesta Statutes Licensed r registered health care prvider: Health care prvider whse license r registratin allws him/her t prvide care and services within the scpe f their respective practices and as authrized frm respective regulatry agencies and May Clinic departmental plicies. Plicy Statements 1. The preventin f drug diversin is essential t the safety f May patients and is the individual respnsibility f every May emplyee. 2. Emplyees are required t reprt knwn r suspected incidents f drug diversin by emplyees, patients, and visitrs. 3. All suspected incidents f drug diversin will be thrughly investigated. 4. Suspicin f drug diversin may arise frm a variety f circumstances, including, but nt limited t, the fllwing: A witnessed incident f prbable drug diversin

2 Behavirs that may indicate an impaired individual (Checklist f Unsatisfactry Jb Perfrmance) Suspicius activity identified during rutine mnitring and/r practive surveillance Self-disclsure f drug diversin by an individual Ntificatin f suspected drug diversin frm an external surce, such as lcal law enfrcement r a family member f a suspected drug diverter 5. Any emplyee wh reprts suspected drug diversin hnestly and in gd faith will be prtected frm retaliatin. 6. The Drug Diversin Respnse Team (DDiRT) will manage the investigatin f all reprts f suspected drug diversin. 7. May Leadership will receive prmpt ntificatin f incidents f prbable drug diversin. 8. Drug diversin by a May emplyee is grunds fr crrective actin. In mst cases the expected utcme will be terminatin f emplyment r dismissal frm the applicable schl r training prgram. 9. Drug diversin by a May emplyee will be reprted t all apprpriate gvernment, licensing, regulatry, and law enfrcement agencies. 10. Data relating t drug diversin reprts and investigatins will be analyzed t identify trends and pprtunities fr ptential imprvement in the medicatin use prcess. 11. The Medicatin Diversin Preventin Subcmmittee has respnsibility fr minimizing the frequency f drug diversin and will crdinate with the May Clinic Clinical Practice Cmmittee fr enterprise management f medicatin use prcesses. Prcedure Statements Initial Reprt and Investigatin 1. Any emplyee wh suspects that drug diversin has ccurred shuld ntify his r her supervisr. Alternatively, an emplyee may call the site Drug Diversin Pager at the fllwing number: Arizna Flrida: Rchester: An emplyee may call the Drug Diversin Pager directly r d s annymusly. If there is n immediate risk t patient safety and an emplyee is nt cmfrtable ntifying his r her supervisr r calling the Drug Diversin Pager, the emplyee shuld call the Cmpliance Htline at t make a cnfidential reprt. 2. Upn ntificatin f suspected drug diversin, the supervisr will perfrm an initial safety assessment and prmptly call the Drug Diversin Pager. Calls made t the drug diversin pager will be returned by a DDiRT representative. 3. The supervisr's initial safety assessment will include the fllwing steps: a) Determine whether any patient has been harmed r placed at risk f harm, and take apprpriate actin t treat the patient r remve the risk f harm. If a patient has been harmed r placed at risk f harm, the supervisr will ntify the patient's primary staff physician. b) Determine whether the suspected drug diversin invlves an impaired emplyee r witnessed drug use by an emplyee. If s, fllw the prcedure fr managing an impaired emplyee.

3 4. The supervisr will take steps that are immediately necessary t preserve any readily apparent evidence, such as medicatin vials r syringes. If evidence invlves an infusin pump, the medicatin will be remved frm the pump and placed in a sealed plastic bag. The pump shuld nt be cleared and shuld be sequestered. The supervisr shuld nt engage in any additinal evidence cllectin r investigatin withut cnsulting with the DDiRT representative. 5. Except as directed by the DDiRT representative r as necessary t cnduct the initial safety assessment, the supervisr will nt interview the individual suspected f drug diversin. 6. Upn ntificatin f suspected drug diversin, the DDiRT representative will initiate a preliminary investigatin and make the fllwing ntificatins: a) If a May emplyee is suspected f diverting drugs while n duty, ntify the Legal Department and the emplyee's supervisr and Human Resurces (HR) service partner. b) If a May fellw, resident, r student is suspected f diverting drugs within the scpe f their training, ntify the Legal Department and the Dean r Administratr f the apprpriate Schl. c) T prtect the cnfidentiality f medical infrmatin, if a patient is suspected f drug diversin, ntify nly the Legal Department and, as needed, the DDiRT. Ntificatin will be limited t the Legal Department and DDiRT even if the suspected patient is als a May emplyee, fellw, resident, r student. I. If a patient suspected f drug diversin is als a May emplyee, infrmatin regarding the suspected diversin shuld nt be shared with the emplyee's supervisr r HR service partner withut apprval frm the Legal Department. II. If a patient suspected f drug diversin is als a May fellw, resident, r student, infrmatin regarding the suspected diversin shuld nt be shared with the Dean r Administratr f the Schl withut apprval frm the Legal Department. d) If a visitr is suspected f drug diversin, ntify the Legal Department and any ther resurces necessary t assist in the investigatin. 7. After the preliminary investigatin, if reasnable suspicin exists that drug diversin may have ccurred, the DDiRT representative will cnvene the DDiRT. 8. The DDiRT will review the evidence and determine next steps which may include further investigatin, additinal surveillance, witness interviews, r suspect interviews. Internal Reprting 9. If the DDiRT cncludes that drug diversin has ccurred r prbably ccurred, the DDiRT will ntify the Legal Department fr internal reprting pursuant t the Plicy n Ntificatin f Leadership Regarding Extrardinary Events. 10. The Legal Department will als ntify the apprpriate billing department t determine whether mdificatins shuld be made t bills related t affected medical care. Emplyment Actin 11. If an emplyee is determined t have cmmitted drug diversin, the emplyee will be subject t crrective actin. In mst cases the expected utcme will be terminatin f emplyment r dismissal frm the applicable schl r training prgram. Such actin may be taken regardless f whether the diversin ccurred within the scpe f emplyment r training, r while the emplyee was ff-duty as a patient r visitr. 12. Terminatin r dismissal due t drug diversin will be recrded in the emplyee's emplyment file r educatinal file. The specific reasn fr dismissal will be shared with prspective emplyers r educatrs wh cntact May with apprpriate authrizatin.

4 Reprting t Law Enfrcement, Licensing Bards and ther Gvernment Agencies 13. If a cntrlled substance is determined t have been diverted by any individual, the Directr f Pharmacy will ensure that apprpriate reprts are made t the Drug Enfrcement Agency (DEA) and the Bard f Pharmacy. 14. If a May emplyee is determined t have cmmitted drug diversin, May Security in cllabratin with the Legal Department will reprt the diversin t the lcal plice department. This reprt will be made regardless f whether the diversin ccurred within the scpe f the emplyee's emplyment r training, r while the emplyee was a patient r visitr. 15. In the event f drug diversin by a patient r visitr wh is nt a May emplyee, the Legal Department in cllabratin with May Leadership will determine whether t reprt the diversin t the lcal plice department. 16. When reprting incidents f drug diversin by a patient, the reprt will describe the facts f the diversin and will nt disclse additinal infrmatin regarding the patient's medical histry, cnditin, diagnses, r treatment. 17. In cllabratin with the Legal Department, the fllwing individuals will reprt drug diversin by licensed r registered health care prviders t the apprpriate State licensing bard: a) The Chair f the Department f Nursing will reprt drug diversin by nurses. b) The Chair f the Persnnel Cmmittee will reprt drug diversin by staff physicians. c) The Dean f the applicable Schl will reprt drug diversin by fellws, residents, r students. d) The applicable Supervisr r ther Departmental leader will reprt drug diversin by all ther licensed r registered health care prviders. 18. The Legal Department and the DDiRT will evaluate all incidents f drug diversin t determine whether additinal external reprts shuld be made, such as reprts t the Department f Health r Fd and Drug Administratin. Patient Ntificatin 19. If any patient is harmed by drug diversin, the patient will be infrmed f the circumstances f the drug diversin and its impact n the patient. The patient's primary physician will be respnsible fr ensuring that this cmmunicatin ccurs. 20. If drug diversin is cnfirmed but it is unclear whether the diversin caused patient harm r placed ne r mre patients at risk f harm, the DDiRT in cllabratin with the Legal Department and May Leadership will determine whether patient ntificatin will serve the best interests f ptentially affected patients. Cllectin, Analysis, and Sharing f Drug Diversin Data 21. The DDiRT will distribute a reprt f each incident f drug diversin t the designated individuals at all May sites acrss the enterprise. 22. The Medicatin Diversin Preventin Subcmmittee will perfrm the fllwing functins: a. Cllect and analyze drug diversin data t identify trends and pprtunities fr ptential imprvement in medicatin use prcesses. b. Share drug diversin data with the May Clinic Clinical Practice Cmmittee t facilitate enterprise management f medicatin use prcesses.

5 Related Dcuments Allied Health Staff Emplyee Plicy Manual -- Crrective Actin Arizna Flrida Rchester Allied Health Staff Emplyee Plicy Manual Alchl, Drug and Chemical Abuse Cnsulting/Vting Staff Plicy Manual Crrective Actin Cnsulting/Vting Staff Plicy Manual Alchl, Drug and Chemical Abuse References NA Cntact Vice Chair, Medicatin Diversin Preventin Subcmmittee (Kevin R. Dilln, Pharm,D.,R.Ph.) Apprved By Clinical Practice Cmmittee - 10/31/2011 Persnnel Crdinating Cmmittee - 12/20/11 Cntent Infrmatin Cntact: Smith, Nami Cntent ID: DOCMAN Release Date: 06/01/2012 Wrkflw Reviewer Name(s): Smith, Nami Wrkflw Apprver Name(s): Smith, Kenneth M. (Ken) Next Review Date: 05/14/2014 Site(s): Rchester, Flrida, Arizna Cmments: Original effective date: 06/01/2012; Date last IPC review 05/14/2012 COPYRIGHT (c) May Fundatin fr Medical Educatin and Research. This infrmatin is intended fr use by May Clinic emplyees nly. It is cnfidential and n part f it may be transmitted in any frm by electrnic, mechanical, phtcpying, r any ther means t anyne utside May Clinic withut the prir permissin f May Fundatin fr Medical Educatin and Research. Inapprpriate use r disseminatin f this infrmatin may result in disciplinary actin. Master cpies are retained nline. Printed cpies are cnsidered current nly n the date printed.