Diversion of Controlled Drugs in Hospitals: A Scoping Review of Contributors and Safeguards

Journal of Hospital Medicine 14(7). 2019 July;:419-428. Published online first June 12, 2019. | 10.12788/jhm.3228

June 12, 2019|Journal of Hospital Medicine

Mark Fan, BASc, MHSc;Dorothy Tscheng, RPh, BScPhm, CGP;Michael Hamilton, BSc, BEd, MD, MPH, CCFP;Bridgett Hyland, PharmD Candidate;Rachel Reding, BASc, MHSc;Patricia Trbovich, PhD

Drug losses and theft from the healthcare system are accelerating; hospitals are pressured to implement safeguards to prevent drug diversion. Thus far, no reviews summarize all known risks and potential safeguards for hospital diversion. Past incidents of hospital drug diversion have impacted patient and staff safety, increased hospital costs, and resulted in infectious disease outbreaks. We searched MEDLINE, Embase, PsycINFO, CINAHL, Scopus, and Web of Science databases and the gray literature for articles published between January 2005 and June 2018. Articles were included if they focused on hospital settings and discussed either: (1) drug security or accounting practices (any drug) or (2) medication errors, healthcare worker substance use disorder, or incident reports (only with reference to controlled drugs). We included 312 articles and extracted four categories of data: (1) article characteristics (eg, author location), (2) article focus (eg, clinical areas discussed), (3) contributors to diversion (eg, factors enabling drug theft), and (4) diversion safeguards. Literature reveals a large number of contributors to drug diversion in all stages of the medication-use process. All health professions and clinical units are at risk. This review provides insights into known methods of diversion and the safeguards hospitals must consider to prevent them. Careful configuration of healthcare technologies and processes in the hospital environment can reduce the opportunity for diversion. These system-based strategies broaden the response to diversion beyond that of individual accountability. Further evidence is urgently needed to address the vulnerabilities outlined in this review and prevent harm.

Most articles did not focus the discussion on any one clinical unit, health profession, or stage of the MUP. Of the articles that made explicit mention of clinical units, hospital pharmacies and operating rooms were discussed most often, nurses were the most frequently highlighted health profession, and most stages of the MUP were discussed equally, with the exception of prescribing which was mentioned the least (Supplementary Table).

Contributors to Diversion

The literature describes a variety of contributors to drug diversion. Table 2 organizes these contributors by stage of the MUP and provides references for further discussion.

The diverse and system-wide contributors to diversion described in Table 2 support inappropriate access to controlled drugs and can delay the detection of diversion after it occurred. These contributors are more likely to occur in organizations that fail to adhere to drug-handling practices or to carefully review practices.^34,44

Diversion Safeguards in Hospitals

Table 3 summarizes published recommendations to mitigate the risk of diversion by stage of the MUP.

DISCUSSION

This review synthesizes a broad sample of peer- and nonpeer-reviewed literature to produce a consolidated list of known contributors (Table 2) and safeguards against (Table 3) controlled-drug diversion in hospitals. The literature describes an extensive list of ways drugs have been diverted in all stages of the MUP and can be exploited by all health professions in any clinical unit. Hospitals should be aware that nonclinical HCWs may also be at risk (eg, shipping and receiving personnel may handle drug shipments or returns, housekeeping may encounter partially filled vials in patient rooms). Patients and their families may also use some of the methods described in Table 2 (eg, acquiring fentanyl patches from unsecured waste receptacles and tampering with unsecured intravenous infusions).

Given the established presence of drug diversion in the literature,^5,7-9,96,97 hospitals should assess their clinical practices against these findings, review the associated references, and refer to existing guidance to better understand the intricacies of the topic.^{7,31,51,53,60,79} To accommodate variability in practice between hospitals, we suggest considering two underlying issues that recur in Tables 2 and 3 that will allow hospitals to systematically analyze their unique practices for each stage of the MUP.

The first issue is falsification of clinical or inventory documentation. Falsified documents give the opportunity and appearance of legitimate drug transactions, obscure drug diversion, or create opportunities to collect additional drugs. Clinical documentation can be falsified actively (eg, deliberately falsifying verbal orders, falsifying drug amounts administered or wasted, and artificially increasing patients’ pain scores) or passively (eg, profiled automated dispensing cabinets [ADC] allow drug withdrawals for a patient that has been discharged or transferred over 72 hours ago because the system has not yet been updated).

Falsification of inventory documentation can involve deliberate miscounting of drug inventory, removing records of drug procurement and intercepting the shipment when it arrives, and forging signatures on drug deliveries from the pharmacy to the care unit. Prevention safeguards include constraining clinical choices, decreasing delays to documentation updates, increasing traceability, and improving verification of transactions. For example, standardizing ordering protocols constrains clinical choices so that minimal controlled drug is dispensed, leading to reduced risk of dispensing more than the patient needs (eg, order sets that avoid dose ranges or limit as needed [PRN] doses). An example of decreasing delays to documentation updates are ADC profiles that rapidly remove discharged patients, so that it is not possible to dispense drugs for a transferred patient. Examples of increasing traceability include biometric (eg, fingerprint) signatures or using cameras in select areas which deter forgery and support auditing. Verification of the transactions listed in the documentation has typically relied upon a real-time witness, but may not always be possible. For example, it is infeasible to require a witness to verify all drug administration to patients. Therefore, future work may be needed to develop other strategies to verify physical transactions (eg, weight sensors and computer vision). Detection safeguards for documentation rely on auditing, therefore electronic systems can be an important asset to employ. For example, electronic systems support monitoring of unusual trends (eg, prescribing activity by care unit or HCW; number of unverified verbal orders; dispensing activity by ADC, care unit, drug, or HCW; variations in patient pain scores between HCWs; drug wastage amounts). If data from multiple systems can be integrated (eg, electronic health records and ADCs), then hospitals can more easily identify discrepancies among the drug amount ordered, dispensed, administered, and wasted or disposed for each patient. Hospitals can also compare purchased inventory against financial records to identify discrepancies. Clinical outcomes can also highlight potential drug discrepancies (eg, uncontrolled pain could be a signal for partial or absent administration of drugs).

The second issue involves failure to maintain the physical security of controlled drugs, thereby allowing unauthorized access. This issue includes failing to physically secure drug stock (eg, propping doors open to controlled-drug areas; failing to log out of ADCs, thereby facilitating unauthorized access; and leaving prepared drugs unsupervised in patient care areas) or failing to maintain accurate access credentials (eg, staff no longer working on the care unit still have access to the ADC or other secure areas). Prevention safeguards require adherence to existing security protocols (eg, locked doors and staff access frequently updated) and limiting the amount of controlled drugs that can be accessed (eg, supply on care unit should be minimized to what is needed and purchase smallest unit doses to minimize excess drug available to HCWs). Hospitals may need to consider if security measures are actually feasible for HCWs. For example, syringes of prepared drugs should not be left unsupervised to prevent risk of substitution or tampering; however, if the responsible HCW is also expected to collect supplies from outside the care area, they cannot be expected to maintain constant supervision. Detection safeguards include the use of tamper-evident packaging to support detection of compromised controlled drugs or assaying drug waste or other suspicious drug containers to detect dilution or tampering. Hospitals may also consider monitoring whether staff access controlled-drug areas when they are not scheduled to work to detect security breaches.

Safeguards for both issues benefit from an organizational culture reinforced through training at orientation and annually thereafter. Staff should be aware of reporting mechanisms (eg, anonymous hotlines), employee and professional assistance programs, self-reporting protocols, and treatment and rehabilitation options.^{10,12,29,47,72,91} Other system-wide safeguards described in Table 3 should also be considered. Detection of transactional discrepancies does not automatically indicate diversion, but recurrent discrepancies indicate a weakness in controlled-drug management and should be rectified; diversion prevention is a responsibility of all departments, not just the pharmacy.

Hospitals have several motivations to actively invest in safeguards. Drug diversion is a patient safety issue, a patient privacy issue (eg, patient records are inappropriately accessed to identify opportunities for diversion), an occupational health issue given the higher risks of opioid-related SUD faced by HCWs, a regulatory compliance issue, and a legal issue.^{31,41,46,59,78,98,99} Although individuals are accountable for drug diversion itself, hospitals should take adequate measures to prevent or detect diversion and protect patients and staff from associated harms. Hospitals should pay careful attention to the configuration of healthcare technologies, environments, and processes in their institution to reduce the opportunity for diversion.

Our study has several limitations. We did not include articles prior to 2005 because we captured a sizable amount of literature with the current search terms and wanted the majority of the studies to reflect workflow based on electronic health records and medication ordering, which only came into wide use in the past 15 years. Other possible contributors and safeguards against drug diversion may not be captured in our review. Nevertheless, thorough consideration of the two underlying issues described will help protect hospitals against new and emerging methods of diversion. The literature search yielded a paucity of controlled trials formally evaluating the effectiveness of these interventions, so safeguards identified in our review may not represent optimal strategies for responding to drug diversion. Lastly, not all suggestions may be applicable or effective in every institution.