Some Knock-Knock Jokes Just Aren’t Funny

What to Do When the DEA Comes Knocking

Key Takeaway: It’s essential for practices to be proactive with their controlled substance security. Completing a gap analysis and tightening up recordkeeping are strong first steps for improving security of controlled drugs.

Ominous Voice: “Knock-knock”

You: “Who’s there?”

If the DEA comes knocking, are you ready? Can you confidently answer their questions and explain your controlled substance security, and recordkeeping, and how it complies with federal and state regulations? If not, then that needs to be a priority because the DEA doesn’t plan their visits at your convenience, and DEA fines are more than $15,000 per violation.

Ominous Voice: “The DEA”

You: “$#!+*%^?#!!!!”

There is no question that controlled substance regulations are difficult to understand exactly what is sufficient and what isn’t. Controlled Substance Acts are written with minimum expectations, but there is also the expectation that controlled drugs are maintained in a manner that provides sufficient security and tracking. What counts as sufficient you ask? Well, that is the million-dollar question, and the answer depends somewhat on all the nuances of each individual practice. There is no one right answer that will fit all practices. Therefore, it’s important to evaluate your current processes and identify potential gaps. The following tips will get you started in the right direction.

The Gap Analysis

No, this isn’t analyzing the gap in your door that the DEA is knocking on. This is analyzing the gap between your current controlled substance practices and a completely secure system. To do this, go through all aspects of the controlled substance lifecycle from ordering through administration or wasting and try to come up with ways that someone could divert drug and be unlikely to get caught. Be honest with yourself on how reliably the double checks in your current policy are actually occurring. What happens when your practice management system goes down? Could someone that knows the workarounds divert some drug without raising any suspicion? Document all the diversion opportunities you find, then start brainstorming what can be done to close the identified gaps.

Recordkeeping

According to Title 21 CFR, Part 1301.91 “A healthcare organization and its employees are mandated to report any incident of drug diversion within the organization.” To be able to report, you must be able to identify the drug diversion. That’s where a strong recordkeeping system comes into play. Cleaning up your recordkeeping will likely help close some of the gaps you identified as well. Recordkeeping can be through electronic logging and documentation, automated dispensing cabinets, paper and pen, or a combination of multiple methods. The method used is only as good as the consistency with which it is done per practice policy. If everyone is finding a loophole and documenting as they see fit, no system will be sufficient. Therefore, the best system is the one that is most likely to be used consistently by everyone in your practice.

With recordkeeping, you need to consider the variety of records required. While you do need to log doses, there are also many other records that are either required or potentially beneficial to address gaps. These include, but aren’t limited to, waste logs, inventory records, discrepancy resolution, med pickups by clients, and documentation of drug receipt. Given the variety of records and variation within each type, such as logging doses in hospital versus on ambulatory calls, it’s important to have a policy or SOP in place that clearly documents the expectations for all things controlled substance related.

When Your Logs Don’t Match Reality

If you are regularly verifying actual quantity on hand compared to expected quantity in your logs, you will have discrepancies. That doesn’t necessarily mean anything was done wrong. However, there needs to be a plan in place for how discrepancies are handled. Solid dosage forms such as tablets, capsules and patches shouldn’t be off because they are being dispensed by a defined unit. However, multi-dose liquids are frequently off (over or under) from the expected quantity. Reasons for this include manufacturer overage, hub loss, leaky vials, and incorrect volume removed. Here are my top tips for handling each of these.

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1. Overfill: Use all the drug in the vial even if your log goes negative. Either create a log entry to adjust your quantity up or go to negative values. Using the drug is often easier than trying to appropriately destroy (and document destruction) of the overfill.

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2. Hub loss: Determine a hub loss amount per stick for your practice. It will vary slightly based on if you are using hubless syringes and needle size. However, I have found that either 0.04 or 0.05 ml per stick is a good average based on the norm of using a variety of syringe types and sizes. When your on-hand amount is less than expected, count the number of sticks and multiply by the hub loss factor. That will determine if hub loss can reasonably account for the missing volume.

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3. Leaky vials: These are challenging to address for drugs where the vial is stuck many times during its in-use life. There are needleless vial adaptors available that can decrease the number of sticks. It also may be beneficial to retrain staff on using the smallest reasonable needle size for drawing up the dose and inserting the needle at a 45-degree angle.

4. Incorrect volume removed: Consider retraining staff to ensure everyone is aware of appropriate technique for reading syringes (hold at eye level, don’t angle, etc.) and ensure that the syringes being used facilitate reading to the desired volume. For example, if the dose is logged as 0.78ml but a 5ml syringe is used, the volume is unlikely to be completely accurate due to syringe marking limitations.

There is a lot to consider with controlled substance security and regulatory compliance. However, it’s important to take a proactive approach to establishing your program and preparing for the day the DEA comes a knockin’.

About the Author: Dr. Lauren Forsythe is a Clinical Assistant Professor of Pharmacy at the University of Illinois Veterinary Teaching Hospital. She is also a diplomat of the International College of Veterinary Pharmacists. Dr. Forsythe graduated from the University of Findlay, College of Pharmacy in 2015 and completed her veterinary pharmacy residency at Purdue’s Veterinary Teaching Hospital. Contact: lforsythe7040@gmail.com

By Jon Detweiler

Watching a professional sports team clinch a national title is awe-inspiring. We cheer and celebrate the collective success of teamwork at the very pinnacle of perfection. Yet on Monday morning, we return to our veterinary practices and struggle to keep the wheels on the bus. We work to keep the staff from fighting, the clients from melting down, and the leadership united. Veterinary leadership teams can be coached and trained, no different than a professional sports team, to be a cohesive, high-functioning team that serves to raise the capacity of the entire hospital staff and drives successful outcomes. Overcoming our dysfunctions and building a strong foundation can set any veterinary team on the road to a championship title.

In his New York Times Best Selling Book, The Five Dysfunctions of a Team, Patrick Lencioni describes a hierarchy of broken behaviors that can cripple a team (figure 1). Lencioni’s methodology begins with absence of trust, which typically stems from an unwillingness to be vulnerable and results in team members who won’t ask for help. Absence of trust creates space for the next dysfunction, fear of conflict. Here, team members cannot engage in the debate of ideas, leading to disingenuous acceptance rather than productive growth. The third dysfunction is lack of commitment, wherein team members fail to engage and ultimately do not commit to the team’s strategic goals. Avoidance of accountability is next and leads to team members not calling out counterproductive behaviors, which further erodes the team. Finally, Lencioni describes how an inattention to results leads to individuals placing their own objectives above that of the collective team. Many teams, if not all, experience some of these dysfunctions at one point or another.

Inattention to Results

If we revisit the champion sports team comparison, we will see parallels in these dysfunctions that would unquestionably lead to failure. Consider a quarterback who doesn’t trust his receiver to run the correct play or a catcher who won’t talk to his pitcher about a run of bad throws or a point guard who doesn’t commit to daily practice and maybe even a striker who is more concerned with his personal scoring record than that of the team. Examples in that context make it obvious that these behaviors are not part of a winning team’s strategy.

Avoidance of Accountability

Lack of Commitment

Fear of Conflict

Using Lencioni’s approach, we can use the inverse of these dysfunctions to strengthen and reorient our team for success. Demonstrate trust in the team, encourage productive discourse around ideas and thoughts, show commitment through action, display radically transparent accountability through the ownership of mistakes and finally, always stay focused on the strategic goals of the practice. Over 85% of teams surveyed revealed that lack of trust is the number one perceived dysfunction, therefore we can conclude that building trust is the most likely starting point.

Absence of Trust

Developing trust requires selfreflection, when we consider our own vulnerability, we see the team differently. Vulnerabilitybased trust normalizes phrases such as “I’m sorry,” “I messed up,” “I need help,” or “You’re better at this than me.” Building trust is an active process that is demonstrated through action. Ralph Waldo Emerson said, “What you do speaks so loudly I cannot hear what you are saying.” Let your actions send clear and consistent messages. Commit yourself to daily practices that build trust, always give others the benefit of the doubt, enthusiastically seek the counsel of others as you work to improve yourself, and participate in your peers’ journeys while celebrating their achievements. Recognize that success is dependent on everyone. Remove I/me/my from your vernacular and replace those words with we/together/ us. Persevere because trust takes time to build. It demands repeated, real-life experiences to forge and requires a consistent example of credibility and integrity.

Albert Einstein said, “In the middle of every difficulty lies opportunity.” Recognizing our potential dysfunctions provides a roadmap for development. Our veterinary leadership teams, as well as our technical teams, customer service teams, and professional teams, are all best served when they train and practice team building daily. Leadership should set an unmistakable example for those that they lead while using every chance possible to demonstrate trust, encourage open discussions, solidify commitment, improve accountability, and focus on the mission. Developing these cohesive behaviors is crucial to building a strong team and a positive practice culture. When teams win, it is not an accident. Teams win because of hard work and dedication. Make a commitment to your team today and help them win that championship title.

About the Author: Jon Detweiler is a seasoned veterinary hospital administrator and leadership consultant in southeastern Pennsylvania. He is a dynamic speaker who presents at national events and has authored a variety of management-oriented articles for veterinary journals and publications. Detwiler has focused on process building/ efficiency, leadership development, and employee performance across several industries including veterinary, public safety, emergency preparedness, and mass event management. His undergraduate degree is in Emergency Management from Hahnemann University, and he has completed executive certificate work through Cornell University with a focus on Change Management. He is a proud “Terv” dad and he enjoys cooking, hunting and traveling with his wife. He can be reached at jdetweiler@vbb.vet.

As of the time of the writing of this update, there are several legislative updates that are of concern to the veterinary profession in Pennsylvania.

Issue 1: Scope of Practice in Large Animal Medicine

The ad hoc committee on the scope of practice of veterinary technicians has been discussing the feasibility of allowing credentialed veterinary technicians (CVT, LVT, RVT) to perform pregnancy determination in cattle either manually or by ultrasound under the indirect supervision of a veterinarian. There have been inquiries from the legislature in Harrisburg about this as a means to alleviate the shortage of rural veterinarians, including discussion about both state board regulation and opening the practice act. The committee is not in favor of either of these options for obvious reasons.

On the other hand, we have received informal communication from the professional licensure committee of the PA House that regulatory or practice act changes are likely unnecessary since the language of the current practice act seems to already allow this, under the indirect supervision of a veterinarian. In addition, credentialed veterinary technicians already can legally perform diagnostic imaging under the practice act. This discussion is ongoing as we try to determine the appropriate path to take.

Issue 2: Pending State Legislation

Victoria’s Law is reappearing in the legislature. This bill seeks to enact a statewide ban on the sale of dogs and cats in pet shops. The PVMA has been on record in the past and continues to be against this legislation. We believe the bill may get out of committee in the House