Insights from Roundtable of Pharmacy Directors’ Discussion of Drug Diversion

On September 22, 2020, Imprivata FairWarning convened a Roundtable of Directors of Pharmacy to discuss drug diversion.  They covered a variety of topics related to drug diversion, including the lasting impacts, red flags, how to identify incidents – with automated or manual solutions, and industry resources.

Drug diversion is an increasingly large problem for health systems. The lasting impacts of drug diversion are widespread, from the effects on patient care – denial of pain relief, bloodborne pathogens, and other patient harm, to the care provider – regulatory liability, fines, and reputational damages, and the diverter themselves – addiction, job loss, criminal record, and family/personal issues.

Participants started by talking about the most common red flags they’ve come across in their careers, for example, excessive wasting in medication cabinets, overdocumentation on an eMAR, and other instances of accessing medications that require further evaluation.  More than one person mentioned cases of drug diverting behavior in otherwise high-performing employees.  This initially went unnoticed due to the fact that these employees had a track record of being extremely helpful with patients in pain, always willing to assist others in the unit, and happily performing duties outside of their roles and responsibilities.

Other red flags include:

• Buddy wasting, which happens when two people are wasting each other’s medications all the time
• Excessive counting of inventory and discrepancies greater than five milliliters during an inventory count
• Canceled transactions, where substitution and tampering can occur, and cycle counts, which present a way to “skirt the system” and access medication without the need for overrides

While it’s important to note that not all of these examples indicate drug diversion; multiple red flags and trends in behavior, especially if anomalous when compared to that of one’s peers, often do.

“We had a pharmacist who was very helpful with compounding of fentanyl drips. Everyone thought that he was just being helpful, but, in fact, he was diverting.”

“We had a nurse that would come to the pharmacy window to pick up doses compared to removing it from their cabinet. They would essentially double remove one from the cabinet one from pharmacy, but they would administer the dispense from the cabinet, so they would pocket the pharmacy dose. That went on for quite a bit until the pharmacy director was picking up, and he noticed the same nurse almost every shift, every night coming through the window picking up doses, and we started investigating, then we noticed there was a trend. Within a week, several doses went missing.”

The discussion shifted to how to best identify potential incidents in your health system. Attendees described a time-consuming manual process involving using a report writer to aggregate data from an EHR and automated dispensing cabinet, then applying logic to review the data and draw meaningful conclusions.

“Right now we have a report writer, who is in my department that I work with, and we pull reports out of our EHR and out of our automated dispensing cabinet system, and we are looking at, and we have some logic built into it that looks at when was this medication pulled, is there a corresponding documentation of administration, and anything that’s outside of our given window, which we have set at two hours, will kind of alert us, and then we chart review from there.  Obviously, Imprivata FairWarning would be extremely helpful in reducing the amount of time we spend on it.”

While time to pore through logs was the biggest pain point with manual monitoring, wasting time “chasing your tail for something that’s not diversion” was also a major frustration. Additionally, attendees worried about what they were not catching and a lack of visibility into what’s really going on. keeps some of our participants up at night.

“What are you missing?  What is happening that I’m not seeing because I’m chasing down something that ends up not being substantial?  That kept me up at night a lot when we were doing a manual system, just that fear.”

Members of the roundtable agreed information sharing within their health systems was crucial to encouraging a culture of compliance. At a minimum, the formation of a patient safety organization, drug diversion committee, response team, or task force that meets regularly (at least once a month) is critical to the success of a drug diversion program. Also, clarity regarding expectations must be provided for all those involved. This helps set the groundwork to start monitoring.

“I think sharing, and just, for example, what you’re doing today on this roundtable discussion is a great way to teach and to learn and to help one another, so thank you.”

All agreed the benefits of automation are many. What’s unique about Imprivata FairWarning, one customer noted, is the personal touch we provide. “Kara and the entire team, having that personal touch, somebody you can reach out to. It’s not just a computer program. Having somebody that is seeing what’s happening around the country and seeing different trends and seeing different hospital systems. That’s a huge benefit for us.” The customer went on to point out that Imprivata FairWarning has a team of industry experts who are readily available to share best practice knowledge with clients to help them detect incidents, as well as guide them through what happens next. It’s not unusual for Imprivata FairWarning to find diverters within a client’s health system in the first 90 days of being implemented. While that’s a good thing, it indicates drug diversion is happening whether you know it or not, and if you don’t have an individual dedicated to diversion monitoring, you’re probably missing it.

Finally, at the end of the roundtable discussion, the Imprivata FairWarning hosts, Tyler and Kara, named a few helpful resources for both customers and non-customers interested in learning more about drug diversion. KLAS is useful for evaluating products in the market. Trainings and community message boards from industry-specific organizations are useful at all stages of building and executing a drug diversion program.  The National Association of Drug Diversion Investigators (NADDI) and the International Health Facility Diversion Association (IHFDA), as well as the American Society of Health-System Pharmacists (ASHP) provide valuable information as it relates to drug diversion. Network contacts can also be good sources of input. As always, for both customers and non-customers, Imprivata FairWarning is here to help, too.

Imprivata FairWarning hosts Tyler Carlson and Kara Earle have expert knowledge gained through years working with customers to detect, investigate, and remediate drug diversion incidents. Tyler has experience investigating healthcare threats, including drug diversion, fraud and privacy violations.  He assists customers with understanding and selecting a proactive drug diversion and privacy monitoring tool.  Kara’s history includes investigating incidents with the Florida Department of Health. She works directly with clients, mining their data to find diversion.