Partially Filled Vials and Syringes in Sharps Containers are a Key Source of Drugs for Diversion

As seen in the Consultant Connection May 2016 Issue
The Institute for Safe Medication Practices recently published practice recommendations related to drug abuse and diversion in healthcare settings. The following has been modified for post-acute and long term care practice settings – full ISMP text is available at
Data from the US Substance Abuse and Mental Health Services Administration show that about 1 in 10 health professionals is struggling with addiction or abusing drugs not prescribed for them. The American Nurses Association reports the same—about 10% of nurses are thought to be abusing drugs and may be caring for patients while impaired. These incidence rates mirror the general population, meaning healthcare workers are not at higher risk of drug abuse than the general population. However, the overall pattern of drug abuse and dependency with healthcare professionals is unique. Studies show a disproportionate misuse of prescription drugs by healthcare professionals when compared to street drugs, primarily because they can access prescription medications easily and often.
Drug diversion and abuse puts patients at risk for suboptimal treatment from diluted or substituted medications, serious infections caused by contaminated needles and syringes, and errors committed by health professionals who are working while impaired. The following recommendations are intended to be practical steps to improve systems for preventing and detecting drug diversion, and dealing with workers who are battling a prescription drug dependency.

Awareness and Recognition of the Problem
Expect diversion. Given that the best estimates are that one in ten healthcare workers will abuse drugs, take all the necessary steps to prevent and detect it. No news is NOT good news when it comes to drug diversion and abuse. 
Observe for signs of impairment and diversion. Educate all healthcare workers to recognize diversion and a drug-impaired coworker. Here are some signs and symptoms:

Changes in behavior
  • Increasing isolation from coworkers and social avoidance at work
  • Frequent illness, accidents, emergencies, tardiness
  • Complaints from others about poor work performance
  • Moody, depressed, irritable, suicidal threats
  • Frequent trips to the bathroom, locker room, unexplained absences, long lunches
  • Illogical or sloppy charting
Physical signs
  • Shakiness, tremors, slurred speech, sweating, unkempt appearance
  • Wearing long-sleeve clothing even in warm environments
Signs of diversion
  • Frequent incorrect controlled substance counts
  • Frequent corrections or illegible documentation
  • Large or inconsistent amounts of wasted narcotics
  • Discrepancies between patient-reported pain and pain medication administration
Report suspicions. Establish an organizational expectation to report suspected drug diversion and worker impairment via a confidential process 
Educate about resources. Routinely provide staff education regarding the resources available if diversion is suspected or a practitioner wants to seek treatment for addiction. 

Drug Security and Chain of Custody
Secure controlled substances at all times
  • Prohibit drawing more than a single dose of a controlled substance into a syringe; saving partial doses in syringes exposes the drug to possible diversion. 
  • Remove controlled substances close to the time they are to be administered. Avoid removing a drug “just in case” a PRN dose is needed.
Manage inventory. Require staff to verify receipt and immediately secure controlled substances. When a resident transfers between nursing stations, the person delivering and the person receiving controlled substances should each cosign on the appropriate record, and the drugs should be immediately secured. 
Restrict access to controlled substances Establish strict guidelines regarding who can have access to controlled substances – do not share keys or leave them unattended. Extra cart keys
Allow no bags. Do not allow purses, backpacks, briefcases, or other personal storage cases in areas where controlled substances are stored, administered, or discarded.
Shift counts. Shift counts must include visual inspection of quantity remaining and package integrity by both nurses. Controlled substance receipts or disposals during the shift must be accounted for and documented.

Safe Drug Disposal
Remaining controlled substance left in a single-use vial: With a witness present, draw the remaining medication into a syringe, require the witness to verify the volume in the syringe, and then squirt the medication into sink or other approved receptacle* while the witness watches. Do not discard the vial in the sharps box before removing and wasting any leftover medication from the vial.* Document the volume and dose of the pharmaceutical wastage, which should be verified and cosigned by the witness.
Wasting extra or partial tablets: When a resident refuses a controlled substance tablet, require the witness to visually identify the tablet to be wasted. If only a half tablet is to be administered, require visual identification of the whole tablet, before the tablet is split, followed by destruction and documentation of the unused portion.
Unused or expired controlled substances: Remove unused, discontinued, or expired controlled substances from the medication cart as soon as possible. Follow proper procedure for documentation of the chain of custody.
FentaNYL transdermal patches: Current manufacturer and US Food and Drug Administration (FDA) guidelines direct users to fold the patch in half with the sticky sides together, and then flush the patch down the toilet. If flushing the patch is not an option, a device that deactivates any remaining drug in the patch should be used prior to disposal. Deactivation and disposal should be documented with a second witness.

Periodic documentation review. Establish a system for reviewing the documentation and use of controlled substances, paying particular attention to:
  • Comparing records of removal of a controlled substance to the medication administration record 
  • Comparing the time of removing a controlled substance to the time of administering the drug (delays could signal diversion)
  • Comparing pain medication administration time to patient reported pain scales 
  • Frequency of pain medication administration to cognitively impaired patients
  • Pain scores and PRN medication usage much higher when a particular staff member is on duty 
Observe staff. Regularly observe how staff manage controlled substances, including wasting drugs, performing shift counts, receiving controlled substances, and other security processes. Also observe staff for at-risk behaviors such as unattended drugs or keys, and coach them to exhibit the desired behaviors. 
Investigate immediately. Start an investigation as soon as it is learned that the count of controlled substances does not reconcile with documentation. 
*Squirting a controlled substance into the sink or toilet may not be an option in some locations or safe for the environment. Squirting a controlled substance into a sharps container may not be permitted by the waste management company that disposes of the containers.

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