14 Operations & Management
Pharmacy Practice News • February 2021
Security
Amid COVID-19, Fight Against Rx Diversion Continues A
n updated set of ASHP Guidelines on Preventing Diversion of Controlled Substances, planned for 20212022, will help hospitals implement best practices using newer technologies. “Our new version will review and evaluate market improvements” targeting diversion from many angles, David Chen, MBA, BS Pharm, the assistant vice president for pharmacy leadership and planning at ASHP, told Pharmacy Practice News. Since 2017, when the first ASHP guidelines (bit.ly/35xqz8v) and 100-point hospital self-assessment test were issued, diverse technologies have reached the market, including: • analytical and artificial intelligence platforms that detect and track anomalous behaviors; • radiofrequency identification (RFID) labels from manufacturers that track medications from the source until administration to patients; and • waste tracking systems. The updated guidelines from ASHP
aim to address “1,000 points across a hospital where diversion could happen, from procurement to preparation and dispensing, to prescribing, administration and waste removal,” Chen said. “Every time you implement a process or tech-driven solution, someone figures out a potential way around it.” The stakes are high for solving or at least mitigating diversion, because the illegal activity poses risks to people who divert as well as the entire health care system, Chen noted. In response, health systems are deploying a wide range of anti-diversion tactics. “They have compliance and regulatory departments, and many are also establishing multidisciplinary controlled substance diversion prevention programs that involve senior leadership because they often require additional resources and policy changes,” he said. “Early adopters also invest in robust analytics and automation.” Massachusetts General Hospital (MGH), in Boston, and Children’s Mercy Hospital, in Kansas City, Mo., are two
A Sampler of Technologies That Curb Diversion Kit Check’s Bluesight for Controlled Substances added two features to its pharmacy module in summer 2020: single sign-on enabling pharmacy staff to access a full suite of solutions without another password, and system benchmarking to drive improvement and standardization of documentation practices across nursing floors and within ORs. BD HealthSight Diversion Management has a machine learning algorithm that looks beyond standard deviations to identify anomalous behaviors and help users correctly conclude investigations. “It does dynamic peer grouping. We compare like nurses caring for the same type patients with the same acuity level and opioid needs. It’s much cleaner to do it that way,” said Alan Frashier, RPh, CPh, MBA, the senior clinical sales consultant at BD. “This pulls it all together [rather than] connect dots that are very disparate in terms of what we ordered, what was pulled from the cabinet, what was actually charged to administer, and what may have been returned, canceled or wasted.” IntelliGuard Anesthesia Station is an RFID-automated medication management cart with end-to-end visibility of usable and end-of-life cycle medications. Users can customize tray pockets to accommodate ampules up to large IV bags; it has two-factor log-in and a biometric ID reader, emergency override access, a large touch screen monitor, and an automated Waste Witness module that issues audit reports, and it can integrate with electronic health records. Fresenius Kabi’s 20-mL vials of Diprivan (propofol). The product, launched in September 2020, ships with embedded RFID labels; prefilled syringes will follow by early 2021. The company said it plans to launch more than 20 other RFIDlabeled medications used in the OR. It claims it is the first pharmaceutical maker to embed medication identification data into the RFID tag following global GS1 standards, permitting full interoperability and compatibility. —A.H.
institutions on the leading edge of such anti-diversion efforts.
Mass General’s Approach At Massachusetts General, the added difficulties of caring for COVID-19 patients drove “higher diversion surveillance efforts overall,” said Christopher Fortier, PharmD, the chief pharmacy officer. Those efforts included an inventory audit following the hospital’s springtime surge “to ensure we accounted for the increased amounts of controlled substances we had to purchase” for the care of the sickest COVID-19 patients, he noted. The hospital’s annual mid-year audit focused on fentanyl, hydromorphone, lorazepam, methadone, midazolam, morphine and oxycodone. Although many factors may contribute to diversion, Fortier cited a few likely culprits. During the first COVID-19 surge last year, MGH had to make rapid adjustments to workflow and other key operations. For example, “we converted general care units to ICUs, and needed nurses and physicians who don’t normally work in the ICU to staff those areas,” he said. Such changes could contribute to breakdowns in the normal checks against diversion, he noted. Coupled with the added stress on health care practitioners, Fortier noted, these factors could explain why institutions have seen more discrepancies and overrides for controlled substances. The response at MGH, where 4,000 nurses administer more than 2 million controlled-substance doses annually, was to “purchase the next generation of [a] controlled substance surveillance system that uses machine learning algorithms. We’ll implement it probably in early 2021. Pharmacy will take the lead on managing it, working very closely with nursing and anesthesia,” Fortier said. “Technology like this is so new that the jury is still somewhat out—though I do know I want a machine learning system to help me identify a diverting worker in possibly a much shorter time frame, and I don’t want to weed through thousands of transactions each day. I want to see the exceptions pulled out of the system each day that show discrepancies and warrant further investigation. Machine learning brings in advanced algorithms to find those exceptions and saves an immense amount of time
looking for the needle in the haystack.” Fortier noted that soon after he came on board at the facility, he was tasked with “cleaning up” after the hospital paid the Drug Enforcement Administration a $2.3 million fine to resolve drug diversion allegations in September 2015. The health system agreed to implement a comprehensive corrective action plan lasting until September 2018. He noted that his institution’s multifaceted, evolving program is based on a culture he implemented “where people know this is serious, that we report appropriately, look out for peers, and put patients and care quality first so they’re never affected by diversion, as far as we know.” Hospital leadership’s interest in the program and in its multidisciplinary collaboration components “remains high,” Fortier added. “We’re always working to get better.” The anti-diversion program includes the following: • An interdisciplinary team of pharmacy, anesthesia and nursing leaders, police and security, human resources, compliance, legal, occupational health and employee assistance. “If someone is diverting and cooperates with the investigation, we want to help them,” Fortier said. • 1.5 FTEs who review drug surveillance data from technology and nursing leaders’ reports of anomalous behaviors (reported daily.) • There also are 170 automated dispensing cabinets (ADCs) with all drugs in individual pockets and blind counts, in which nurses don’t
