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Improving Processes Can Reduce Risks of Drug Diversion


The hospital can be a chaotic place. When a clinical floor is busy, it’s easy for details to fall through the cracks, processes to be forgotten, and mistakes to occur. Healthcare workers are already stretched thin trying to provide quality, attentive care. But if carefully laid processes are overlooked, the risk to patients increases.

Terri Vidals is no stranger to the hospital floor. As a former clinical pharmacist, she enjoyed working with nurses and other staff providing direct care to patients. But as her career shifted to a role in controlled substance monitoring, she started to pay more attention to problems that affect healthcare workers – namely, substance abuse, drug diversion and how they can compound the dangers to patients.

“The shift to monitoring controlled substances gave me a different perspective,” said Vidals. “I became more aware of substance abuse issues when I saw colleagues struggling and saw diversion events occurring. It was surprising to see that hospital leaders were not always aware of it or refused to believe it.”

Many facilities don’t have programs for monitoring medications in place because, as Vidals puts it, “no news is good news.” She says that hospital leaders owe it to their patients, institutions, and their employees to have a comprehensive drug diversion prevention and monitoring program in place. Those insisting they don’t have a problem simply aren’t looking.

“Statistically, between 10 to 14 percent of healthcare workers are addicted to either drugs or alcohol, which is no different than the general population,” said Vidals. “That percentage seems to be increasing because of several societal and environmental factors. Hospitals are not immune to employees with substance abuse issues.”

- Healthcare is an extremely stressful occupation. Especially now, when facilities are still struggling with the pandemic, people can feel overwhelmed and overworked.

- Healthcare workers can easily access medications. Some of the most potent medications available are within their reach – and with little supervision.

- They don’t think it can happen to them. Most healthcare employees are familiar with how these medications work and the effects they have. This gives some the wrong impression that they can control things without it turning into a substance abuse problem or a danger to themselves.

One way to reduce risks to patients and healthcare workers is to revisit medication processes. Vidals suggests that hospitals tighten their chain-of-custody procedures. From the time hospital pharmacies receive the drugs to the time they are administered or wasted, processes need to be in place and followed. This includes establishing a separation of duties within the pharmacy to limiting the number of medication orders written for a patient. These processes allow for patients to get the medications they need while minimizing access and potential diversion by workers struggling with substance abuse.

Above all, Vidals suggests instilling a culture of honesty and transparency in the hospital. This culture will encourage reporting of suspected diversion as well as medication errors. Mistakes happen, she says, but how an organization deals with human error can make a difference in reducing the risk that they don’t happen again.

“Recently, a nurse accidentally gave the wrong medication to a patient,” recalled Vidals. “But she recognized how somebody else could easily make that same mistake, so she reported herself. The nurse was devastated because the patient could have suffered a serious injury. But she did the right thing, and a new process was created to prevent it from occurring again.”

“Everyone – pharmacists, nurses, physicians – needs to feel comfortable admitting their errors, so the facility can take the necessary steps to correct processes and prevent patient harm from happening. Proactively looking for ways to improve a medication process will help curb them. Those mistakes will continue to occur when hospitals refuse to report or respond to them.”

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