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.'"