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    Hospitals wage battle against drug diversion

    Recently, a former nurse who worked at the Veterans Administration Medical Center in Bedford, the Somerville Hospital, and the Metro West Medical Center-Framingham—all in Massachusetts—was sentenced because she stole numerous controlled substances, including codeine, oxycodone, and fentanyl, from these facilities. She had falsely stated on medication administration records that she was administering the medications to patients, all the while keeping the medications for herself.

    Drug Topics contacted the hospitals involved to find out what measures they have put in place to prevent such thefts in the future, but all three declined to comment.

    Diversion of controlled substances and other pharmaceutical products is recognized as a critical problem in the United States. Many hospitals are fighting back, however, by utilizing medication monitoring devices, such as Pyxis machines from Cardinal Health, and tighter medication distribution security to assist them in preventing drug diversion.

    The Pyxis machine has a series of drawers and pockets to hold various medications. Narcotics and controlled substances are stored in a carousel drawer that keeps track of amounts dispensed. "Technology helps a lot. There are statistical programs that we can use to look at the medications that have been withdrawn from the Pyxis machines. If more medication than normal is withdrawn, it sends us an alert," stated Timothy Lesar, Pharm.D., director of pharmacy at Albany Medical Center in New York State.

    Drug diversion by patients or by individuals posing as patients may result in harm to the people themselves or to other people around them. Healthcare professionals have easy access to controlled substances, and some will divert and abuse medications to relieve stress or enhance alertness and performance. According to the National Council of State Boards of Nursing, approximately 15% of healthcare professionals struggle with drug dependence at some point in their career. Drug diversion can result in substandard care by, and ultimately the death of, the healthcare provider.

    Drug diversion in the hospital setting can occur when patients receive medications on an as-needed (PRN) basis. Part or none of the medication is given to the patient exactly on schedule during the shift, but a nurse documents that the maximum amount of the medication was administered. Numerous instances of this have been reported.

    A few years ago, an emergency room (ER) nurse at Champlain Valley Physician's Hospital, Plattsburgh, N.Y., stole a number of controlled substances, including morphine and methadone, from the hospital's pharmacy department or the ER's locked narcotics cabinet. In order to conceal the thefts, the nurse falsified hospital records to indicate that the medications had been ordered by physicians to treat ER patients. However, in most cases, the medications were never ordered, the patient was not in the ER on the specified date, or the dosage was incorrect.

    Removing injectable controlled substances from their container and replacing them with saline solution is another form of drug diversion. A former nurse at Morehead Memorial Hospital, Eden, N.C., pleaded guilty to stealing morphine while at work, secretly swapping the clear liquid drug with water. Each time, the caps were cut off syringes filled with meperidine and the drug was drained out. Later, the nurse refilled the syringes with saline solution and glued the caps back on.
    "There are still a lot of gaps. We cannot watch everything that every person does. However, technology allows us to let people know that we are still watching," said Lesar.

    Excessive wastage is another method to divert drugs in hospitals, explained Lesar. "Although a witness is required for the wastage of controlled substances, many times the nurse diverting the medication does not get a witness. The nurse will later request a verifying signature from another nurse on the shift with the excuse that she was too busy to get a signature at the time the medication was discarded."

    In addition to the available technology, all employees should be able to recognize the signs and symptoms of medication diversion, such as patients who receive more pain medications but are reporting ineffective pain relief, as well as frequent reports of lost or wasted medications. Staff members need to know what to look for and how to report suspicion or knowledge of medication theft within their facility. "Management needs to observe their employees and look for these signs of abuse, especially if they suspect something unusual," said Lesar.

    Other control measures that hospitals are utilizing to prevent drug diversion include random drug tests, criminal background checks, a review of the medication distribution process, and development of a facility-wide awareness of the need for thorough investigation into all occurrences. If there is a suspected drug diversion, it should be reported to the pharmacy and nursing administration, who should work together to solve the problem. "In our institution, the pharmacy department makes sure that all the controlled substances are accounted for. If there is a discrepancy, we need to investigate it right away and find out the reason for it," Lesar concluded.

    THE AUTHOR is a writer based in New Jersey.

    Julio Fernandez, PharmD
    The author is a writer based in New Jersey.