Implementing Systems for Detection and Prevention of Drug Diversion

Transcription

1 Implementing Systems for Detection and Prevention of Drug Diversion Mitch Sobel, RPh, Assistant Director of Pharmacy Services Saint Barnabas Medical Center, Livingston, New Jersey Aline Greene, RN, CEN, Pyxis Nurse Liaison Roper Saint Francis Healthcare, Charleston, South Carolina Elaine Jones, RPh, MBA, Director of Regulatory Compliance Cardinal Health Pharmacy Management Friday, January 27, 2006

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

3 How Big of a Problem is Drug Diversion? 6-15% nurses abuse drugs found in hospitals Indiana Board of Nursing 12 anesthesiologists die from overdoses of fentanyl a year; abuse drugs 3x the general physician population American Society of Anesthesiologists

4 Top Rx Drugs of Abuse Hydrocodone (Vicodin, Lortab, Lorcet) $6 - $8 Oxycodone (Oxycontin) $.50 - $1/mg (Percocet, Percodan, Tylox) $6 - $10 Acetaminophen (Tylenol #3, Tylenol #4) $3 - $5 w/codeine Diazepam (Valium) $1 - $2 Propoxyphene (Darvon, Darvocet) $2 - $4

5 Top Rx Drugs of Abuse Carisoprodal (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 - $60 Fentanyl (Sublimaze) $35

6 Other Significant Problems Stadol Nasal Spray Proventil Ultram Phenergan Codeine containing cough syrup Methadone Ketamine High Expense Drugs: Neupogen, Epogen, Growth Hormone Life Style Drugs: Viagra, Propecia, Nolvadex

7 Warning Signs Staff members seeing changes in co-workers behavior Employee asking to witness excessive wastage Continuous issues with inventory management

8 Employee Warning Signs Deteriorating job performance. Psychological changes. Behavioral changes. Changes in physical appearance. Length of addiction may result in employees showing no signs at all.

9 Methods of Enabling Failure to recognize warning signs. Attributing signs to other causes (stress, illness, etc.). Provides coworker with password. Co-signing g wastage not observed. Making excuses for person not following narcotic handling procedures.

10 Common Denominators Employees on medical leave: Post-surgery Post-injury Other factors: Stress Family issues History

11 Typical Nurse Profile Best nurse on the floor Never would have suspected him/her Willing to work extra shifts Stays late after shift ends Comes in early for shift

12 Typical Nurse Profile Agency/Registry nurse Divorce/child custody Recent health problem Death/illness in family

13 Typical Nurse Profile May show up on off days Prefers night shift Prefers high narcotics floors Signs out more narcotics than peers

14 Typical Nurse Profile Frequently documenting waste Nursing notes do not coincide with drugs given Frequent restroom breaks

15 Typical Nurse Profile Using drugs on the job Record keeping becomes sloppy Impaired or passed out at work place Patient complaints Co-worker complaints

16 Typical Nurse Profile Using Schedule II injectables (Demerol, Morphine, Dilaudid ) Self addicted Not trafficking

17 Pharmacy Nurse Liaison Position Work closely with pharmacy and nursing with any issues related to medication administration. Review the Standard Deviation Reports for possible offenders and send reports to managers for review Report the every other month narcotic chart audit for the nurse managers Complete in-depth review if needed d in conjunction with Director of Nursing and Director of Pharmacy

18 Random Narcotic Chart Review Overall Compliance with Narcotic Documentation Jan-05 Mar-05 May-05 Jul-05 Waste Doc 88% 97% 97% 100% Effe ct. Doc 80% 72% 75% 68% Overall Com pliance w ith Narcotic Docum entation 100% 80% 60% 40% 20% 0% 88% 97% 100% 80% 72% 68% Waste Doc Effect. Doc Waste Documented Jan-05 Mar-05 May-05 Jul-05 2nd Center 100% 100% 100% 100% 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-05 2nd 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%

19 Diversion Prevention 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. Securing purchases and wastes. Utilization of technology ogy closed cosedeecto electronic c loop.

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

21 Reports and Data Interpretation Controlled Substances Vault Access Report. All Events Report. Controlled Substances Vault Compare Report. Review Send Report. Automated Dispensing Machine (ADM) Report. Purchase History Report. Proactive Controlled Substances Diversion Report. Documented Discrepancies Report. Waste and Return Report. Overrides Report. Inventory Verification Report. Report Title Documentation (Discrepancy Y or N, If Y then detail) Initials CII Safe Pyxis Compare N (covers 24hr period, run Bi-monthly) Y Proactive Diversion Report N (covers week period, run monthly) Y All Station Events for Nurse Managers N (covers 72hr period, run Bi-monthly) Y Open Discrepancies (available on console screen) See Controlled Substances Discrepancy Log Documented (i.e. Resolved) N Discrepancies Y (covers 24hr period, run Bi-monthly) Waste and Return N (covers 24hr period, run Bi-monthly) Y Overrides N (covers 24hr period, run Bi-monthly) Y All Station Events N Patient Chart Review Y (run monthly) Inventory Verification Report N (all units, 1 rotating item, run monthly) Y DATE TIME OF EVENT PATIENT OCCURRENCE OF EVENT CARE AREA DESCRIPTION OF DISCREPANCY RPH REPORT RECEIVED YES NO DISCREPANCY RESOLUTION All Station Events for Nurse Managers (Consultant). DATE OF EVENT TIME OF EVENT PATIENT OCCURRENCE CARE AREA DESCRIPTION OF DISCREPANCY RPH REPORT RECEIVED YES NO DISCREPANCY RESOLUTION Open/Unresolved Discrepancies (Console Screen).

22 Standard Deviation Report (>3) listed by employee / by Month Standard Deviation Report (>3) -- listed by employee / by Month total # deviations total # deviations Employee Name Alice P., RN 1 09/04 3SL3 Aline H., RN 1 09/05 3SL Amy B., RN 1 3/04 3SL1 02/05 3SL2 Beverly W., RN 1 09/04 3SL1 3 08/05 3SL1 10/05 3SL2 Brian K., RN 1 06/05 ER Carol M., RN 2 11/04 PCU 12/04 PCU 1 1/05 PCU Casey G., RN 1 1/05 3SL Catherine R., RN 1 08/04 SPCU 2 03/05 SPCU 10/05 SPCU Colleen A., RN 1 07/05 PCU Darby G., RN 1 07/04 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 LDRP Diane K., RN 1 2/04 4SV2 1 05/05 PCU Diane P., RN 1 04/05 ICU Donna S., RN 1 07/05 LDRP

23 Specific Nurse Review --- Removals & Wastage User Name Pt ID Pt Name Transaction Time Transaction Type Medication Description Witness Qty Name Text NURSE,NAN BARB 08/06/05 00:45 Removed MORPHINE SUL 2 mg/1 ml INJ 1. NURSE,NAN BARB 08/06/05 03:31 Removed MORPHINE SUL 2 mg/1 ml INJ 3. NURSE,NAN BARB 08/06/05 06:19 Removed MORPHINE SUL 2 mg/1 ml INJ 3. NURSE,NAN BARB 08/06/05 20:35 Removed MORPHINE SUL 2 mg/1 ml INJ 3. NURSE,NAN BARB 08/06/05 23:30 Removed MORPHINE SUL 2 mg/1 ml INJ 3. NURSE,NAN BARB 08/07/05 04:20 Removed MORPHINE SUL 2 mg/1 ml INJ 3. NURSE,NAN BARB 08/07/05 20:58 Removed MORPHINE SUL 2 mg/1 ml INJ 3. NURSE,NANNAN BARB 08/07/05 22:42 Removed MORPHINE SUL 2 mg/1 ml INJ 3. NURSE,NAN BARB 08/08/05 04:35 Removed MORPHINE SUL 2 mg/1 ml INJ 3. NURSE,NAN KEVIN 08/06/05 23:16 Removed meperidine hcl 50 mg/1 ml syringe 1. NURSE,NAN KEVIN 08/07/05 03:13 Removed meperidine hcl 50 mg/1 ml syringe 1. NURSE,NAN KEVIN 08/07/05 07:21 Removed meperidine hcl 50 mg/1 ml syringe 1. NURSE,NAN KEVIN 08/07/05 22:40 Removed meperidine hcl 50 mg/1 ml syringe 1. NURSE,NAN KEVIN 08/08/05 01:27 Removed oxycodone-apap 5/325 tablet 2. NURSE,NAN KEVIN 08/08/05 03:06 Removed meperidine hcl 50 mg/1 ml syringe 1. NURSE,NANNAN 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 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 AMY 08/20/05 22:37 Removed morphine sulfate pca 30 mg/30 ml vial 1. NURSE,NAN 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 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 AMY 08/21/05 21:16 Removed LORAZEPAM 2 mg/1 ml vial 1. NURSE,NAN AMY 08/21/05 22:30 Removed HYDROMORPHONE HCL 2 mg/1 ml INJ 2. NURSE,NAN AMY 08/21/05 23:22 Removed morphine sulfate pca 30 mg/30 ml vial 1. NURSE,NANNAN AMY 08/21/05 23:26 Wasted from StationHYDROMORPHONE HCL 2 mg/1 ml INJ NATHAN AMT GIVEN: 0 mg (AMT WASTED: 4 mg) NURSE,NAN 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 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 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 MARIE 08/27/05 02:33 Removed MORPHINE SUL 2 mg/1 ml INJ 3. NURSE,NAN MARIE 08/27/05 04:18 Removed MORPHINE SUL 2 mg/1 ml INJ 1. NURSE,NAN MARIE 08/27/05 04:59 Removed MORPHINE SUL 2 mg/1 ml INJ 2. NURSE,NAN MARIE 08/27/05 06:39 Removed hydrocodone-apap 5/500 tablet 3. NURSE,NANNAN MARIE 08/27/05 21:10 Removed MORPHINE SUL 2 mg/1 ml INJ 3. NURSE,NAN MARIE 08/27/05 22:20 Removed hydrocodone-apap 5/500 tablet 3. NURSE,NAN MARIE 08/27/05 23:22 Removed MORPHINE SUL 2 mg/1 ml INJ 3.

24 Diversion Stories Removing other meds (Benadryl, Vistaril, Phenergan ) giving i it IV instead of the narcotic Putting the narcotics in a towel in the ceiling of the lounge, found when water line broke 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 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 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

25 Narcotic Diversion Schemes Narcotic pull for excessive amounts of patients. Pull larger dose than patient receives. Remove drug from IV drips. Pattern of broken vials and ampoules. 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.

26 Narcotic Diversion Schemes continued Pulverized or broken tablets. Pieces of tablet or powder of capsule missing. Substituting diluent for active injectable narcotic in IV bags. Substituting look alike legend drug tablets for active narcotic tablets (Bingo cards, blister packs). Heated needle through bottom of glass ampoule 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.