There are several steps to creating a successful drug diversion monitoring program, including achieving executive buy in and ensuring the right teams are assembled to implement the program across the organization. When assembling these teams, it is incredibly important to take into account the organization’s unique structure as this needs to be considered for the program to be most effective. The diversion monitoring program will rely on the skill and competency of the teams tasked with the advancement of the program and ensuring a culture of compliance.
Read the entire Controlled Substance Diversion Monitoring Playbook to review all eight steps for creating a proactive diversion monitoring program. This playbook is a helpful guide for healthcare organizations that are either starting, in the midst of creating, or optimizing their current drug diversion monitoring program.
Here are the teams necessary to ensure a successful diversion monitoring program:
They are the true gatekeepers when it comes to Controlled Substances (CS) in your institution, safeguarding the DEA license that allows health systems to administer these medications. This team is on the front lines of CS administration and are essential for monitoring supply and detecting anomalies that indicate potential drug diversion.
Human Resources (HR)
As a critical component of any diversion team, HR advocates for both workforce members’ rights, as well as the needs of the institution with regard to human capital. Ultimately, any serious diversion incident will involve HR, and should be included as a key stakeholder.
Occupational health employees are often essential when it comes to setting up a plan for drug testing and completing fitness-for-duty exams. They may also support a program for bloodborne pathogen testing in suspected diversion cases.
Diversion teams that involve anesthesia are able to leverage the unique insights Anesthesiologists have due to their critical role in the Operating Room (OR). This insight makes the Anesthesiologist a great agent to spot potential diversion activities. The need for tight CS monitoring in the OR is essential, along with the monitoring of gas usage and symptomatic signs of the patient under sedation as they may be potential signs of drug diversion.
Placing Security on the diversion monitoring team provides an important skill set to the group that can enhance the capabilities of the team to investigate and resolve potential incidents of diversion. In some cases, Security is sworn law enforcement and can be used for criminal investigations and prosecutions. If not, they should have a good relationship with local law enforcement to be able to integrate them into the investigation when needed and be the liaison for the institution.
As the department that is ultimately responsible for avoiding major regulatory fines and ensuring procedures and education for institutional compliance, some organizations have Compliance take a point position in a diversion team, bringing together all stakeholders under a unified authority. Drug diversion can fall under their wide umbrella of Compliance, and the inclusion of these experts can help the entire team understand the range of issues and their various potential outcomes.
Most diversion incidents will also have to involve the Legal team of a hospital, given the potential institutional risk and complexity around liability associated with patient involvement. Having these individuals involved can help the team stay up-to-date on potential legal issues that may arise.
This team may want to be involved in diversion decision-making and/or provide resources on this front, given the significant institutional liability represented by controlled substance diversion.
This team is an important addition to an integrated diversion team, given the significant safety impact diversion events can have on patient outcomes.
Unfortunately, nursing staff are very likely to have team members who are diverting drugs. Nurses also represent the largest group of employees who have direct access to controlled substances and have the clinical context to under whether prescribing practices are normal versus abnormal. This means that nurse managers, and sometimes, nurses themselves, should serve on the core team.
Forming these teams will ensure your organization is given the opportunity to take the necessary steps to create a robust and practical drug diversion monitoring program that reduces risk across your organization and ensures patient and workforce member safety.