Development of a Road Map to Controlled Substance Diversion

PreventionRene Cronquist, RN, J.D.

Director of Practice and PolicyMinnesota Board of Nursing

In the news….

“Prison Sought for Nurse Who Stole Drugs”

“Nurse Accused of Stealing Patient’s Prescription”

“Nurse Pleads Guilty to Stealing Narcotics from Patients”

Concerns

• Patient safety– Patients deprived of necessary pain medications– Potential for overmedication if subsequent doses

are adjusted based on lack of pain relief– Infection (contaminated IV meds)

• Nurse impairment while on duty• Fear, reluctance to trust nurses• Cost

Beyond the headlines…

• Controlled substance diversion is a problem that concerns a number of parties.

• Each party had been

addressing the problem from their point of view, with little coordination among the parties.

How to build a better mousetrap

• May 2011 – the Minnesota Department of Health and the Minnesota Hospital Association assembled a coalition of stakeholders to address controlled substance diversion.

• Many of the parties that ultimately became involved in this project had a history of working together on other patient safety issues through the Minnesota Alliance of Patient Safety (MAPS).

The Coalition

Participants included representatives from: Associations of health care organizations Infection Control County attorney Law enforcement – local, DEA and FDA Large health systems Retail pharmacy & health system pharmacists Health Boards (Nursing, Medicine, Pharmacy) Boards’ alternative monitoring program (HPSP)

Narrowing the Universe

• The Coalition quickly realized the problem of drug diversion is vast and multifaceted. To be timely and effective, the group decided to be clear and concise about its focus.

• The focus became controlled substance diversion (as opposed to all drugs that might be diverted) and the acute care setting (hospitals).

Objectives

• Identify best practices and resources to prevent and increase awareness of diversion.

• Guidance to parties on how, when and with whom information may, can and/or must be shared.

• Recommend measures to quantify cases of diversion.

• Disseminate information to health care providers and organizations and the public.

How to accomplish the work

• Work groups– Best practices/resources for prevention,

awareness and detection of diversion– Communication across coalition organizations and

investigative organizations– State and Federal reporting obligations– Dissemination of resource materials– Identification of measurements to gauge scope of

the issue and impact of the coalition work

Prevention Roadmap Outline

• “SAFE” infrastructure

• Best Practices Principles

• Tool Kit

“SAFE”

• S: Safety teams/Organizational structure• A: Access to information• F: Facility expectations• E: Educate staff and patients

SAFE infrastructure

• Organization defines, and the structure supports, an effective CS diversion prevention program

• Proactive collaboration with law enforcement• Commitment to collection, auditing and review of

relevant data• Organization sets and communicates expectation

that staff “speak up” when a potential diversion concern is identified

• HR practices support organization-wide diversion program

Best Practices

• Procurement• Storage and security• Prescribing• Preparation and dispensing• Administration of CS• Handling wastage• Follow-up if diversion is suspected

Tools in the Tool Kit

• Includes:– State and Federal laws and rules– Diversion Prevention Coordinator position

description– Internal investigation checklists– Diversion investigation agencies– Diversion reporting obligation flow sheet– Articles and websites regarding substance abuse

and identifying the impaired practitioner

Diversion Investigation Teams

• Recommendation for a team to respond to any irregularity in controlled substances.

• Team assists with determining what investigation is appropriate and coordinates or assists with coordination of investigation.

• Examples: Code N or Drug Diversion Investigations Resource Team (D DIRT)

• Includes reporting to external agencies (e.g. law enforcement and Boards)

Outcomes of the Process

• Very beneficial to have the wide array of participants. – In addition to identifying best practices, the

coalition members developed helpful connections with other members. Better understanding of the roles, perspectives and challenges of each party. (Knowing who to call about what and when)

– Greater buy-in– More outlets for dissemination of information

Next steps

• Disseminate information

• Encourage adoption of best practices

• Continued communication among coalition members

• Measure effectiveness• Develop tools for other

healthcare settings

Report, Roadmap and Toolkit

http://www.mnhospitals.org/inc/data/drug-diversion-toolkit/drug-diversion-final-report-March2012.pdf

http://www.mnhospitals.org/inc/data/drug-diversion-toolkit/controlled-substance-diversion-prevention-roadmap.pdf

The Minnesota Hospital Association - Controlled Substance Diversion Toolkit

All of the above will soon be posted on Board’s website: www.NursingBoard.state.mn.us