It is hard to believe that a long-time healthcare professional at your hospital is suddenly the focus of a drug diversion investigation. Upon a closer look, subtle patterns begin to emerge showing a history of missed medications, unexplained waste alerts, and discrepancies in dispensing logs. These red flags, often buried in mountains of data, can be easy to overlook without a structured approach.
Drug diversion investigations are complicated. They shine a spotlight on a moment, incident, or pattern that isn't always comfortable, especially for those who are responsible for resolving it. With the introduction of new technologies, information overload, and a desire for irrefutable evidence, your progress can quickly stall. It is essential to understand the evolution of investigations and to establish an effective, efficient process.
How drug diversion investigations evolve
From the moment you realize there is something that needs additional review to creating your final report, the journey of a drug diversion investigation has changed over time. What used to be a very manual process is now enhanced by diversion tracking technology, but that increased ability to track information can also be overwhelming. How do you know if you're approaching drug diversion investigations appropriately? There is a desire not only to keep your patients safe but also to ensure the people diverting the drugs feel supported rather than penalized.
To ensure that your investigation hits all the key stages without being stalled by overanalyzing data or putting off interviews, you can follow this defined pathway:
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Stage 1 - Discovery: This is the catalyst for further action. You uncovered an incident through one of four primary avenues: A discrepancy or alert in the data
- Complaints or tips at the hospital
- A visible incident or moment of impairment
- Frequent and consistent surveillance
- Stage 2 - Initial investigation: Data is being gathered and reviewed, and a deeper dive is initiated, or an incident occurred that is being responded to.
- Stage 3 - Interview: The investigator speaks directly with those involved with the diversion.
- Stage 4 – Adjudication: The decision or after-action stage of the investigation, where documentation and reporting occur.
Key elements of a drug diversion investigation
While the stages can feel very linear, there are a few different paths that your hospital's drug diversion investigation process can take. All investigations will begin with discovery, but after the initial investigation, it is essential to determine whether it warrants an official investigation or whether it is a practice issue that additional training can resolve. In either case, always have proper documentation, no matter what path the investigation takes.
Drug diversion investigations are complex. It can be easy to stall or lose momentum due to various factors, so it is vital to keep the scope of the issue in check. With sophisticated drug detection software, it can be hard to tell how much data is enough. How do you know you're even ready to move on from the initial investigation phase to the interview? By understanding and specifying the scope of the investigation, you will be able to determine how much data evidence is necessary. Outline what those points are in the process that signifies it's time to move to the next stage. Defining the process can be especially important to move from investigation to interview. It can be easy to get lost in the weeds trying to find every answer, but the interview stage can provide many of those answers.
Throughout the investigation, ensure proper documentation. This will establish and maintain the integrity of the investigative process from discovery to adjudication. Proper documentation also aligns with regulatory requirements and best practices and provides data for tracking the effectiveness of your program.
Discovery: Best practices for gathering essential data
Discovery is the first stage in the process; however, it is not a simple step. In our State of Drug Diversion report, we surveyed health leaders for their perceptions of drug diversion monitoring programs, and 81% of them believe that most drug diversion goes undetected. Let's dive into the best practices for using drug diversion technology, like Sentri7 Drug Diversion, to gather information at this stage.
The first place you want to start in your application is the people. You must review data consistently to monitor trends and changes in behavior. If you are short-staffed, focus on the top two people in each hospital unit with the highest number of activities and the highest scores. If you have more capacity, expand the list. The idea is to search for patterns using the dashboards available to you. You can parse the data in several ways by searching for everyone showing a number of missed medications, administrative alerts, or waste alerts. Don't skimp in procedural areas, focus on what is doable for you and your team, and be consistent with reviewing the data.
Are you checking your badge access readers? What time did your staff go in and out of a room with a locked automated dispensing cabinet (ADC)? Do their logs for medication dispersal or waste match these patterns? Are you reviewing cameras? Are you wasting testing? All of these and more can be essential for discovering drug diversion. It is up to your team to understand where to start and how to keep it manageable.
Initial investigation: Is this diversion?
During your consistent data reviews, you start to notice concerning data. How do you know it is time to present this data to your department leaders? To demonstrate what diversion may look like, we will examine the case of "Jeff," a hypothetical hospital employee in the Cath Lab. For an in-depth look at how the investigation process was used to discover "Jeff's" diversion, you can see the full clip below. Here is a brief look at the initial investigation.
Jeff is a well-liked, long-term employee at the Cath Lab with no complaints against him. However, it has been noted in his file that he recently had ACL surgery. The Sentri7 Drug Diversion dashboard shows a low HEAT score, indicating nothing is obviously flagging as a concern. If the investigator had relied solely on this score and had not conducted consistent data or procedural area checks, Jeff would not be considered a concern.
Over the course of 90 days, the investigator noticed a small ramp-up in Jeff's practice and policy violations. While Jeff had a dispense rate for fentanyl and midazolam that was only a little above his peers, he also had 20 full-dose waste alerts with no explanations and was often recorded as not following best operational practices.
Once these concerns started to appear in the bi-weekly data and procedural area reviews, the investigator had a team member verify and cross-check all the information in the EHR, Pyxis, and through the cameras. All of the information was documented and shared with the nursing leadership. So, is it diversion?
In this case, the evidence and data collected made it clear that a conversation with Jeff was needed, and everyone is ready to move to the interview stage. When considering if a case is diversion or just a practice issue, the investigator must consider the case in its entirety. Are there regulatory concerns due to this action? Are there contributing factors such as recent surgeries or life changes? Is there any indication that this incident could lead to patient harm? Sometimes the investigation may conclude that there were process or workflow issues, which can be a great opportunity to refine, re-train, and enforce policies.
