By Gary Evans, Medical Writer

Although it is rarely detected, experts tell us that drug diversion by healthcare workers is a rampant and longstanding problem. There certainly is no reason to think it is less so today, with an opioid epidemic raging in the community.

As employee health professionals are increasingly involved in preventing drug diversion, it is well to remember that the addict can resist everything but temptation. Locking and securing crash carts and pharmacy supplies on a given unit is critical to prevent drug theft or some form of tampering and substitution.

The Healthcare Facilities Accreditation Program (HFAP) recently released an analysis of 88 HFAP accreditation surveys, finding that 16% of citations were related to the security of medications. HFAP pharmacy services standard 25.01.03 requires that all drugs and biologicals are stored so as to prevent unmonitored access by unauthorized individuals, explains Donna Tiberi-Blaszczyk, RN, BS, MHA, a member of the HFAP standards interpretation staff.

HFAP standards specify that units that provide 24-hour care are generally considered “secure” when hospital policies limit entry and exit to appropriate staff, patients, and visitors. A unit that is not currently in use is not considered secure. In that case, the hospital may choose to lock the entire suite, to lock non-mobile carts containing drugs and biologicals, or to move mobile carts to a locked room, according to HFAP. All Schedule II, III, IV, and V drugs must be kept locked within a secured area.

“For example, anesthesia carts should be locked at all times when there is no one in the room,” Tiberi-Blaszczyk says. “Because anyone could walk into the room and take out propofol or fentanyl. What we are looking for if you are going to have an anesthesia cart in the OR — and that cart isn’t visible to the OR staff, or the OR is closed — then that cart has to be locked.”

Similarly, carts that contain these medications should be maintained in a visible traffic area.

“For instance, make sure someone at the nursing station is always available to identify anyone who tries to access the cart,” she says.

Medication cart locks are usually plastic with an identification number, which should be recorded so it is clear when the lock was changed.

“The crash cart should be checked each shift to make sure that the lock wasn’t changed, that the lock number is the same,” Tiberi-Blaszczyk says.

If the cart was accessed, the medication taken and the healthcare worker responsible must be documented.

Pyxis medication dispensing machines need to be monitored, with overrides the exception and not the rule, Tiberi-Blaszczyk says.

“You need to monitor Pyxis access,” she says. “How many overrides do you have, and how are they validated? You need to know who is getting access to the medications and what they are taking out.”

Bearing Witness

Surveyors also will ask what procedures are followed when it is determined that a narcotic is missing. Controlled medication counting should be completed by two people who sign off on the process.

“There is one that is counting and one is making sure the count is correct,” she says. “When you do a controlled medication inventory check, you have to account for what was taken and if something is missing. If there is a missing vial of something, nobody should go home until you find out where it went.”

Discarding opened but unused opioids also should be done in tandem.

“When medications have to be wasted, make sure there is a witness,” Tiberi-Blaszczyk says. “We want to ensure morphine, fentanyl, and propofol are being wasted appropriately. There should be a double signature.”

The use of witnesses would give pause to any momentary temptation while making diversion more logistically difficult.

“This way, no one can be in a position to divert,” she says.

A common problem is that demands for space lead to placing medication carts in alcoves or blind spots.

“You have to be able to physically see your crash cart and Pyxis so you know it is not being tampered with,” she says.

Employees can store the carts in a locked room, but that immediately raises the question of who has access to the key or key code where the cart is secured.

The HFAP report found that most deficiencies result from inconsistent adherence to hospital policy for securing medications, increasing the risk of access by unauthorized individuals. For example, often housekeeping and engineering staff have access to secure areas via master keys.

Other examples of surveyor citations included that drugs are delivered from the pharmacy to open bins in medication rooms that can be accessed by non-licensed personnel.

Somewhat surprisingly, the report also wrote up units for having no daily accounting system for what is removed by whom from the medication inventory.

“Usually in hospitals and ambulatory settings you are allocated an inventory so you know what you order in terms of medication,” she says. “Those controlled substances are dictated by the needs and services you provide. We shouldn’t survey and find controlled meds sitting out on a pharmacy counter or in a department counter. That should never happen, and if so, it should be immediately addressed.”


1. HFAP. Mastering the Standards for Survey Success: The 2018 HFAP Quality Review. Available at: