There is an increasing focus on safe use of needles and vials, which was the subject of a Sentinel Event Alert from The Joint Commission last year, says Vicki Allen, MSN, RN, CIC, infection prevention coordinator at Beaufort (SC) Memorial Hospital.1
“The Joint Commission [Alert] was actually on the misuse of vials, but in talking about it, obviously diversion is one of the misuses of the vial,” Allen says.
As a result, many healthcare facilities are emphasizing the proper use of single-dose vials and trying to limit access to multi-dose vials that could be contaminated. “The recommendation is to have single-dose vials whenever possible, and that’s going to decrease the risk that you have multi-dose vials sitting around that can be accessible to those looking [to divert],” Allen says.
In addition, the common practice at her facility is for the pharmacy to provide the smallest dose possible for a given patient in the drug dispensing container, she adds.
“So if the patient is ordered morphine, the pharmacist is going to supply the lowest dose vials that they can, keeping the volume as low as possible,” Allen says. “Decreasing the volume of the drug availability is one way we can control it. Then another part of that is an audit. Make sure you are doing audits on your units to look for open vials and any kind of red flag that would clue you in to some kind of diversion activity or patient exposure.”
With patient safety advocates pushing for more involvement of patients and families in their medical care, there also are opportunities to assess pain levels that could raise the possibility of diversion, she adds. “Taking pain medication away from patients is essentially harming them,” Allen notes. “By involving the patient and their families during rounding, this sort of thing can be addressed [by asking], ‘Is your pain being controlled?’ You may trigger something, and that’s happening more and more.”
While it does appear that incidents of drug diversion are increasing overall based on media reports and journal articles, that also might be a surveillance artifact of looking harder for signs of diversion activity, Allen adds. “It may be just that we are more aware,” she says. “It’s on the radar, so we are looking for it more. Patient safety is such a huge factor now. People are doing audits, more surveillance, mandatory reporting.” Also, there is more oversight by the Centers for Medicare and Medicaid Services (CMS), Allen says.
In that regard, a recently finalized hospital infection control survey for CMS inspectors does not cite drug diversion specifically, but focuses a lot of attention on the proper use of needles, syringes, and single-dose and multi-dose vials. Surveyors are instructed to observe injection safety practices in two units of the hospital if possible.
The CMS conditions of participation to protect patients from harm are certainly applicable to drug diversion, which also is addressed in accreditation standards and is a felony in every state, says Kim New, RN, JD, an independent consultant who previously founded a program to detect diverters at the University of Tennessee Medical Center [UTMC] in Knoxville.
“The standards are out there. There is a regulatory aspect for hospitals to meet, but most of the time, unfortunately, the standards are not specific enough [to require] the hospital to have the ‘ultimate’ program and security measures,” she says.
Regardless, healthcare facilities should have every incentive to establish strong diversion prevention programs because patients infected or exposed by drug diverters might be entitled to considerable compensation. Citing the huge sums some juries have awarded to patients infected through injection safety lapses and oversights, a drug diversion expert says similar results might be coming for diversion outbreaks.
“[C]onsider that every healthcare facility that handles divertible drugs is at risk for an unscrupulous healthcare worker not only diverting drugs, but doing so in a manner that could harm patients and others,” Keith Berge, MD, an anesthesiologist at the Mayo Clinic in Rochester said in an editorial accompanying a CDC study.2 (For more information on that study, see previous story.) “Then the question becomes not ‘How can we afford a program to prevent and detect drug diversion by health care workers?’ but instead ‘How can we afford to not have such a program?’”
The risk of diversion could remain relatively constant in healthcare given the toxic combination of addiction, medication, and access. “Unfortunately, the plague of drug diversions cannot be fully exterminated because highly intelligent, desperate, and motivated addicts (e.g., addicted nurses and physicians training in or working in drug-rich environments) will continue to seek ways to obtain the highly desirable and abusable drugs housed within health care settings,” Berge warned.
1. Joint Commission. Preventing infection from the misuse of vials. Sentinel Event Alert 2014; Issue 52. Accessed at http://bit.ly/14WXZff.
- Berge KH, Lanier WL. Bloodstream infection outbreaks related to opioid-diverting health care workers: A cost-benefit analysis of prevention and detection programs. Mayo Clin Proc 2014; 89:866-868.