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Curing What Ails Hospitals

DRUG DIVERSION—where hospital personnel steal prescription medicines from the facility—is on the rise. Diversion leads not only to the loss of expensive and controlled medications but also to the termination of otherwise skilled and worthy medical staff. In cases where medicines are diluted or substituted, it can also cause unnecessary suffering or worse for patients.

In one 2009 case, a surgical scrub technician who worked at two Denver-area hospitals was addicted to narcotics and carried the blood-borne disease hepatitis C. She injected herself with syringes of fentanyl, meant to lessen patients’ post-surgery pain. The technician then refilled the syringes with a saline solution and returned them for recovery room use. As a result, more than 15 patients were not only denied pain relief, but they were also infected with hepatitis C.

In the Milwaukee, Wisconsin area, Aurora Health Care, a not-for- profit healthcare provider with more than 170 sites throughout eastern Wisconsin and northern Illinois, including 14 hospitals and more than 155 clinics, was seeing an upswing in drug diversion, according to Michael R. Cummings, CPP, director of loss prevention services for Aurora and chairman of the ASIS International Board of Directors. “Over a period of about a year and a half, we were averaging in our Greater Milwaukee hospitals about one case a month of a nurse diverting narcotics for their own use,” says Cummings. “It was pretty significant.”

New technology and practices that help reduce the likelihood of diversion and aid in the detection in cases where it does occur have been developed and the Greater Milwaukee facilities had implemented some of these in recent years, including the installation of an automated dispensing system, increased auditing of the use of narcotic pharmaceuticals, and a manager and employee awareness program.

In the past, narcotics control at hospitals was by a paper log system, explains Cummings. Drugs were traditionally kept in locked cabinets to which keys were distributed. When nurses removed drugs, they logged in the date and time, the patient’s name and ID number, the drug and amount taken, the nurse’s name and ID number, and other information that was later added to the patient’s medical record and the bill for the hospital stay.

The system Aurora Health Care chose for the Greater Milwaukee facilities was the Pyxis Medstation, by Pyxis Corporation of San Diego, California. The units not only control the dispensing of the medication to staff with assigned PIN numbers but also initiate automated recordkeeping, with each transaction’s date, time, drug, patient, and nurse being electronically recorded and available for auditing.

The information is also automatically sent to the facility’s billing department and attached to the patient’s medical records. “We don’t have to have somebody reconciling all the handwritten copies anymore,” states Cummings.

The information captured by the Pyxis Medstations, Cummings says, can often help catch diverters, such as in cases where a nurse enters a name and ID number and dispenses narcotics ostensibly for a patient who it is later discovered was released from the hospital earlier in the day.

In addition to having that type of system in place, Aurora Healthcare also began looking more closely at the nature of the problem. Last year, Cummings and his team began a review of the drug-diversion cases at Aurora’s hospitals. The study revealed a pattern.

“We found that about 70 percent of the diverters were long-term employees and good nurses who had come back to work after a personal injury or illness for which they had been prescribed some sort of pain medication,” says Cummings. “Their prescriptions ran out. They came back to work, and they thought they were fine. But then perhaps they had a bad night.”

Cummings explains that nurses often suffer from the same “superman/superwoman” syndrome as doctors do, meaning they believe they are strong and smart and can handle this “just this one time,” he states.

“Their reason for diverting a medication to themselves often has altruistic roots. They think, ‘I’ll do this one time. I don’t want to leave my patients and my coworkers in the lurch tonight. I can handle this,’ and in fact they are as human as everyone else. It’s a slippery slope, and they get hooked,” explains Cummings.

“The concern is that we are losing a lot of good nurses. And even though they are bright people and should know better, they are coming back to work and letting themselves fall into this trap,” Cummings states.

With the root cause of the problem revealed, Aurora was better able to craft a targeted solution. In a response also based on altruism, loss prevention personnel worked with Aurora’s behavioral health experts to create an education program for human resources and nursing supervisors.

HR and nursing supervisors get information on addictive personality types as well as the sorts of noticeable physical and behavioral signs that are associated with narcotics addiction. The program stresses the red flag of a medical leave of absence due to something like a personal injury.

Under the program, narcotics addiction awareness information is now provided to all nurses who are taking medical leaves of absence. “We’re really underscoring it,” says Cummings. “We’re saying, ‘When you come back this can happen.’”

In addition to advising nurses generically that this can happen, they are provided with a tip sheet of specific warning signs to be aware of and clear direction to see their personal physician, consult with employee health, or see a drug counselor through the employee assistance program if they need help for pain management or believe that they are potentially developing an addiction. The goal, says Cummings, is to ensure patient safety and save the careers of these valuable employees.

The awareness training is working. Cummings says that the number of diversion cases has dropped sharply since the drug diversion education program has been in place.

Moreover, cases that do occur are more likely to be reported by nursing supervisors. Now that they are more aware of the signs of narcotic addiction—including trembling hands, sleeping on the job, and increased mistakes—supervisors have been bringing their suspicions to Aurora loss prevention, Cummings says. A supervisor might say, “‘Susie has been acting weirdly, and she fits the profile you educated us on. We think something is wrong,’” says Cummings.

After that type of supervisor report, “loss prevention initiates a call to the hospital pharmacy department to check… Pyxis records for the last several months and see if a pattern has been established outside the norm,” Cumming states.

“For example, if Susie is a part-time nurse working weekends only, and the average number of scheduled medications for pain given out by these types of nurses is 20 per week, and suddenly, she’s giving out 100 per week, we ask ‘What’s wrong with this picture?’”

The hospital pharmacies also now conduct regular audits of nurse’s electronic drug-dispensing records. Among the clues to possible diversions are narcotics dispensed using the medical code PRN, indicating it was at the nurse’s discretion for pain. Audits have revealed instances where the amount of narcotics that appeared to have been given to patients by the nurse during the shift far exceeded what was safe; in those cases, what’s really happening is that the patient receives what he or she should get, but other doses are diverted.

“Obviously, we have to ask how the patient needed 15 of those pills in one night,” Cummings says.

Interviews with the nurses have usually led to admissions. “What is heartbreaking is that these are very good employees, and sometimes [they] have been working for us for as long as 10 to 15 years, but [because of the drug diversions] they are going to lose their jobs and be reported to the state, receive a license sanction so that they have to go through some kind of impaired-professional program to get their licenses back, or they may be permanently suspended. Their careers are put at risk,” he states.

Depending on the facts of the case, says Cummings, “We have the option to report it to law enforcement. But more often than not the nurse is a 40-year-old woman with no previous record except perhaps an old speeding ticket. Prosecuting them is going to end with little more than what the state licensing board will do. In fact, they are more likely to get more help and pay a greater penalty from a license sanction than a prosecution.”

The exception to that are the cases in which drugs were diverted for resale and in which a nurse has jeopardized a patient; those cases are formally reported to law enforcement.

Overall, Cummings is pleased with the results. “We will continue to monitor this, but early results show a success story here,” he says. His message to other healthcare security professionals is that “by educating the managers and talking to these nurses up front and keeping an eye on them afterward,” says Cummings, “loss prevention can help the hospital avoid the financial costs, save jobs, and make sure that patients are getting the best care.”