Presentation Outline ICHP Annual Meeting September 13-15

Methods: Identifying Users Users
• Report 1: Users with >3 SDs (SD) above the mean removal of any controlled
substance
AND
• Report 2: Users with >2 SD above mean compared to station level peers for given
class of controlled medications
AND
• Report 3: Users with >2 SD above mean compared to all hospital users for given
class of controlled medications
AND
• Report 4: Users with >2 SD above mean compared to station level peers on a
daily basis for given class of controlled medications
Behavioral Indicators
Methods: User Audit
• Isolates self
• Frequent disappearances
• Unscheduled visits
• Vl Volunteers t ffor additional dditi l shifts hift
• Frequently spills/wastes narcotics
• Chaotic home life
• Refused compliance with
investigations
Patient Care Indicators
• Incorrect charting
• Inconsistent work quality
• Offers to help other nurses’
patients
• Removes excessive amounts of
narcotics
• Requests specific patients
• Inadequate pain control with
patients
Siegel J, O’Neal B. Code N: Multidisciplinary Approach to Proactive Drug Diversion Prevention. Hosp
Pharm. 2007:42(2);244-248
Methods: Discrepancy Audit
• Controlled substance discrepancies were reviewed over the
same period assessing for type and severity
– Level 1: Miscounting
– Level 2: Mechanical error
– Level 3: Inappropriate pp p documentation
– Level 4: Incorrect administration
– Level 5: Inadequate resolution
Methods: User Audit
• Users had all removals of controlled substances in previous 30
days audited for documentation and potential diversion
episodes:
– Removal without order
– Removal without documented administration
– Removal in excess of order that does not require waste
– Removal in excess of order that requires waste without appropriate
waste documentation
Methods: User Audit
Number marked “Yes” Level of Risk
0‐2 Points Low
3‐4 Points Medium
>5 Points High
Siegel J, O’Neal B. Code N: Multidisciplinary Approach to Proactive Drug Diversion Prevention. Hosp
Pharm. 2007:42(2);244-248
Results
Indicator Nov. 2011 Dec. 2011 Jan. 2012 Feb. 2012
Doses Dispensed‐ ADM 62,016 60,049 59,784 54,918
Average Daily Doses‐ADM 2,067 1,937 1,929 1,894
C‐II to C‐V Dispense 5,208 4,348 3,788 3,649
% C‐II to C‐V 8.40% 7.24% 6.34% 6.64%
Total C‐II to C‐V
Discrepancies
42 36 29 13
% C‐II to C‐V Discrepancies 0.81% 0.83% 0.77% 0.36%
Total Overrides 2,938 3,137 3,015 1,995
C‐II to C‐V Overrides 891 931 897 623
% C‐II to C‐V Overrides 1.44% 1.55% 1.50% 1.13%
8/29/2012
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