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10 Ways to Halt Drug Diversion by Healthcare Workers

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   September 02, 2016

The Mayo Clinic is a leader in dealing with opioid-addicted physicians, nurses, and technicians and the risk they present to patient safety.

This article was originally published on June 12, 2014.

The Mayo Clinic, is rigorous about preventing opioid-addicted workers from stealing injectable drugs and putting patients at risk. It may be more relentless in its efforts than any other healthcare organization in the country.

That's because it has encountered the problem so often—at least 40 times in the last five years, says Keith Berge, MD, a Mayo anesthesiologist who chairs the clinic's Medication Diversion Prevention Committee and heads the Minnesota Board of Medical Practice.

Knowing that opioid-addicted clinicians are out there, the Mayo, with 59,000 employees in five states, now looks harder than ever to find them.

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The focus on healthcare worker diversion started 15 years ago, Berge tells me. That's when the clinic realized it was sending at least one anesthesia worker a year into treatment for fentanyl addiction, one of the drugs to which that specialty has easy access.

Then in 2008, the clinic discovered that a catheterization lab nurse at Mayo's hospital in Mankato, MN was stealing patients' fentanyl, using the syringe on herself, then replacing it with saline for use on the patient "so cath lab patients were getting no sedation for their procedures," Berge says.

"It ended up being on the front page of the Minneapolis Star Tribune, and caused a lot of angst at the highest levels. People suddenly realized, 'Jesus, this is a very scary problem. We need to make it stop.' "

Fortunately, no patients had been infected. Yet.

So the Mayo created D-Dirt, the Drug Diversion Intervention and Response Team led by a special diversion coordinator. The team developed policies for various units. The prevention and detection ball started to roll.

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The bomb dropped, in 2010. It was every hospital's worst nightmare.

That's when the clinic discovered that Steven Beumel, a drug-diverting radiology technician in its Jacksonville, FL facility, had infected five patients with hepatitis C. Beumel, who had worked for the Mayo since 1992, was later convicted and sentenced to 30 years for infecting patients.

One of the patients died.

Here's what Berge says happens at the Mayo now, and what he believes every hospital in the country should consider implementing to avoid controlled substance abusers among their workers:

1. Have a zero tolerance policy for theft of any drugs from anywhere. And have a zero tolerance policy for any worker who fails to properly witness a coworker disposing a drug that is not ultimately given to the patient.

Make sure workers know the hospital considers this so serious, that they will lose their jobs and be reported to the appropriate authorities. Emphasize that this behavior puts patients in danger.

Have a pre-employment drug screening program and an education campaign that stresses trying fentanyl or another opioid out of curiosity, even one time, is not safe. "People say I'll just try it once. But fentanyl is so profoundly addictive that's it. It's over," Berge says. "I say it's like they found the orgasm button and they can push it every day, all day long."

2. Make friends with law enforcement agencies, such as local police or U.S. Drug Enforcement officials, who can process search warrants of employees' homes and cars to help prove a case. This helps put the case on the record so prospective employers can be warned.

3. Employ a 24-hour diversion hotline for workers to report suspicious behavior. Advertise the program with a slogan such as "Save Your Co-worker's Life," which the Mayo posts on its Pyxis machines.

Staff the hotline with qualified personnel and resources to enable prompt response to tips or concerns. Make sure that responders have authority to take prompt and appropriate action.

"The point that we hammer on is not that you are ratting out your colleague, but that this puts our patients in terrible danger, and your colleague in danger of losing their life," Berge says.

4. Assemble a team like the Mayo's D-DIRT. This includes a full-time Medication Diversion Prevention Coordinator, who is either a pharmacist or a certified pharmacy technician. The coordinator conducts educational campaigns, supervises D-DIRT activities, and helps investigate case reports.

5. Employ a waste retrieval system everywhere injectable opioids are used in patient care. This entails enforcing a strict policy that quantities of all drugs drawn that aren't used on patients be securely returned to a Class 2 controlled substances vault in the pharmacy, under the watch of cameras, for reconciliation with both the Pyxis and anesthesia records. This process checks that what's returned squares with what was drawn and what was given to the patient.

Randomly test drugs retrieved to make sure they are the real drugs. "People often inject syringes in the bathroom stalls, and so it is just as likely the syringe is filled with toilet water, because that's the water they have available to them when they're injecting," Berge says.

Start with the high-risk areas, such as the operating room suite, then recovery room, the emergency department, GI endoscopy, interventional radiology and cardiology. Consider adding other areas throughout the hospital and outpatient settings as resources permit.

Berge acknowledges that such systems are labor-intensive, logistically cumbersome, costly, and create another possible avenue for diversion among those charged with returning the drugs.

But everywhere the clinic has implemented such a system, "to our utter, jaw-dropping amazement, it has almost stopped diversion completely." While not foolproof, he says, "it somehow creates a mental barrier in peoples' minds that 'if I do this I'll get caught.'"

6. Throw out assumptions about healthcare workers who divert drugs:

They are easily noticed because of their odd behaviors. They are not, and they are skilled at hiding their activity. They are often the best workers who come in early, stay late, and volunteer to do extra work.

They are rarely discovered in regions with low opioid use. Wrong. Diversion happens everywhere there are healthcare workers. Especially where there are healthcare workers, because that's where the drugs are. Minnesota for example, has one of the lowest rates of opioid overdose in the nation, but in Rochester, there are a lot more healthcare workers per capita than the rest of the state.

Only workers with access to drugs divert them. Not true. While it's mostly nurses who divert drugs because their numbers are so large, people in every job description in the Mayo system have been caught diverting drugs, from janitors to nurses to physicians, even a toxicology lab tech who, as he tested the fentanyl for evidence of diversion, was caught diverting.

None of the major incidents nationally in recent years, which required notification and testing of 30,000 patients, involved workers whose job description gave them access to controlled substances.

Berge says that a hospital executive has not yet been caught, "but it will happen." The Mayo has even had several healthcare workers caught diverting drugs while they were patients in the hospital.

7. Know and keep track of areas throughout your organization that are the most vulnerable, from the loading dock to the incinerator and update them when new diversion schemes are detected.

8. Report it. Have a policy that when an employee is found to be diverting drugs, the hospital has an obligation to report that to the DEA, as federal law requires. The hospital also should report to the responsible state professional licensing board or hospital licensing agency, and if the diverter is a physician or dentist, to the National Practitioner Data Bank. 

9. Make sure hospital leaders understand that as healthcare systems get better at creating barriers to theft of controlled substances where they are stored, the theft that does occur will happen closer and closer to patient care, at the bedside, "at the stopcock of the IV."

Berge says that today, it's harder for an addicted healthcare worker to steal oxycodone from a hospital pharmacy, because of newer policies that secure and account for it. So don't be surprised if they are more successful wherever the drugs are used.

10. Offer treatment once an employee is caught and terminated. Even extend healthcare benefits that provide coverage. "We say, 'You're fired. Now how can we help you.'?"

While the Mayo may have an aggressive prevention program, however it still finds problems because, perhaps, it is just looking harder to find them.

Just last week, Berge says, he got another call from a nurse in tears. It had happened again. That nurse had taken a vial of fentanyl and syringe out of the Pyxis for a patient and handed them to a second nurse who eagerly volunteered to draw it up and administer it.

But the first nurse saw that the syringe inserted wasn't the same one that she had handed the second nurse. D-DIRT was called and the syringe returned to the toxicology lab for its contents to be tested

"It wasn't fentanyl," he sighed.

"These people are very good at covering their tracks. They're hard to catch. And I think that's the message we're trying to get out. It's terrifying, but you have to look for it."

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