by Eric Russell

THE DEVELOPMENT OF AN EFFECTIVE DRUG DIVERSION PREVENTION AND detection program is a major concern for hospitals and hospital pharmacies, in particular. Many hospitals now use automated dispensing machines (ADMs) to control their staff’s access to narcotics and other medications. Although ADMs offer excellent control features for automating medication use, their reporting systems can be limited when it comes to identifying potential cases of drug diversion.

The Case in Point
The Grant Medical Center and Riverside Methodist Hospital in Franklin County, Ohio, members of the OhioHealth Corporation health system, had been using Pyxis ADMs for approximately 14 years. In 2001, a floatpool nurse in the OhioHealth system had been diverting dilaudid from ADMs, by tampering with vials to steal the drug, and then replacing the vials in the ADMs. Although we eventually proved the nurse had an 80% higher dilaudid usage rate than other nurses, this discrepancy was not initially revealed in the Pyxis report—a problem our investigative services team attributed to the system’s inability to report on trends beyond a 30-day data-storage limit.

Once the evidence of tampering was discovered and a drug name was identified, the team ran a number of Pyxis reports to collect evidence. The investigation required a tremendous number of man-hours, as the Pyxis reporting environment required time-consuming data entry and report compilation. After our investigators identified the information needed to build a case, that information was retyped from the Pyxis report into Excel spreadsheets, a task that took weeks to complete.
Because of the potential impact that drug diversion has on patient care and safety, and given the extensive number of man-hours spent on generating reports, the investigative services team determined that we needed to implement a variety of changes in light of the September 2001 case. We formed a task force and began developing a proactive and comprehensive drug diversion plan. Initial changes included ordering tamper-resistant drug packaging, implementing internal policy changes, and launching a hospital-wide education program on drug diversion and safe dispensing system practices. In addition, the investigative services team was now charged with monitoring and tracking drug diversion, freeing pharmacy management to spend more time on patient safety and care. We also sought to procure a Pyxis-compatible software program that would allow us to better track medication usage patterns.

The Solution
After evaluating several medication-usage reporting tools, we selected the Pandora Data System, based on the following criteria:

• It interfaced with our hospitals’ existing Pyxis ADMs.
• It could be implemented in a short timeframe.
• Dispensing data could be directly imported into Pandora with a minimum amount of effort, and it was easy to integrate the import process into our workflow.
• Pandora provided the hospital with ready access to dispensing data beyond Pyxis’ 30-day data-storage limit.
• Pandora’s Anomalous Usage Reports, Discrepancy Reports, and Activity Reports would be effective tools in our drug diversion prevention program.

Detecting Drug Diversion With Pandora
We export data from our ADMs to Pandora on a weekly basis, and then run Pandora’s reports to monitor narcotics usage. We have also implemented quarterly audits that include:

• Running a Pandora Anomalous Usage Report to show medication usage trends for the entire hospital every three months. It takes just a few minutes to generate this report, and the bar chart format allows investigators to easily flag individuals with a high anomalous-usage pattern. Although the report is not necessarily indicative of a problem, it does identify individuals with transaction anomalies worthy of further examination.
• Running a Pandora Activity Report to look more closely at users with high anomalous-usage patterns. The report provides a detailed look at user activities to help us draw conclusions. For example, if a pain drug is being withdrawn with twice as much frequency as it should under normal circumstances, the investigative services team will review patient charts. Other flags might include Schedule II narcotics withdrawals in close succession.

After identifying a possible drug diverter, investigative services and nurse managers work together to determine the appropriate course of intervention.

Results
By using Pandora, we immediately reduced the time we spent generating reports. Instead of spending two to three weeks reviewing Pyxis reports to collect data, investigators can generate Pandora’s Anomalous Usage Report in a matter of minutes, and we are able to generate reports that help us monitor every ADM user—from full-time employees to temporary staff and float nurses. Pandora has also improved the auditing efficiency at both hospitals.
Furthermore, because Pandora Data Systems provides us with ready access to ADM data beyond the Pyxis system’s 30-day data storage limit, we can now easily review longer-term trends in medication usage to determine if medications are being diverted. With Pandora, Grant Medical Center and Riverside Methodist Hospital can unequivocally say that we proactively monitor our hospitals’ narcotics supply.

Pandora in Action
During a recent quarterly audit of Riverside Methodist’s emergency department, a Pandora Anomalous Usage Report revealed that an unusually large number of morphine injections had been removed from one of the ED ADMs. The data from a Pandora Activity Report indicated several questionable transactions warranting further scrutiny. We were able to identify a temporary contract employee, working as a travel nurse, who had been removing morphine and dilaudid at a rate eight times higher than his coworkers.

Using Pandora’s reporting tools, we are now able to identify, investigate, and resolve drug diversion cases in an expedient manner. Pandora’s product is helping us meet our goal to prevent and eliminate the problem of drug diversion.

Senior investigator at Grant Medical Center and Riverside Methodist Hospital, Eric Russell has worked as an investigator with OhioHealth Corporation for 10 years. He also currently serves as the treasurer of the National Association of Drug Diversion Investigators.