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NARCOTIC DIVERSION

NARCOTIC DIVERSION. THE HSC EXPERIENCE Jan Beales, Pharmacy Linda Carroll, Pharmacy Roberta Lowry, Nursing Monique Yakiwchuk, Pharmacy. OVERVIEW. Who are we? What were our challenges? What were our solutions? What are the current barriers?

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NARCOTIC DIVERSION

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  1. NARCOTIC DIVERSION THE HSC EXPERIENCE Jan Beales, Pharmacy Linda Carroll, Pharmacy Roberta Lowry, Nursing Monique Yakiwchuk, Pharmacy

  2. OVERVIEW • Who are we? • What were our challenges? • What were our solutions? • What are the current barriers? • What are our future plans? • What is our wish list?

  3. Who are we? • 850 bed tertiary bed teaching hospital • Catchment area- Province of MB and northwestern Ontario • Hospital footprint 32 acres • HSC Staff – Total 7,000 • 3,800 nursing staff • 150 pharmacy staff • 90 anesthesiologists

  4. Who are we? • Unit Dose Distribution- includes both cart fill and Pyxis/CIVA • Pyxis Operations – Pharmacy/Nursing Operations Committee • Pyxis Equipment (46 wards) • 62 Pyxis Medstations • 41 Pyxis Auxiliary cabinets • 1 tower • CII Safe

  5. OVERVIEW • Who are we? • What were our challenges?

  6. NARCOTIC DIVERSION

  7. What were our challenges? • 2001 completely manual narcotic system • 2002 Pyxis on 20 Adult patient care wards • many areas still a manual narcotic system & a manual narcotic vault • High volumes of narcotics • 167,000 T3 tablets/year • 103,000 morphine 10mg/ml amps/year • 20,000 fentanyl 100mcg/2mL/year • Security –over 4,000 staff in database– difficult to maintain • Reporting tool deficiencies • Limited resources for proactive surveillance

  8. OVERVIEW • Who are we? • What were our challenges? • What were our solutions?

  9. What were our solutions ? • Proactive Audit

  10. THE PROACTIVE AUDIT Roberta Lowry , Nursing

  11. THE PROACTIVE AUDIT Mandate: (March 2005) • Develop a business plan for a Proactive Narcotic Diversion Monitoring Program • Plan to include software, P&P, education & staff

  12. THE PROACTIVE AUDIT Deficiencies of Existing System: • Pyxis: insufficient data reporting (1 mo.) • Pandora: reports don’t combine mirrored MS • No dedicated EFT positions • No data to project workload requirements

  13. THE PROACTIVE AUDIT Starting point: Anomalous Use Report: Hospital–Wide All Stations Report (for 9 mo) Findings: • 547 potential “highly likely” diversions • 819 potential “highly suspect” diversions

  14. THE PROACTIVE AUDIT Where do we start???????

  15. THE PROACTIVE AUDIT Narrowing the choices…….. • Select a drug likely to be used in many areas • Select an area with a single MS ……..and the winner is

  16. THE PROACTIVE AUDIT Diazepam 10 mg tablets

  17. THE PROACTIVE AUDIT Next step…… • Pandora Anomalous Use Report for selected MS nurse patient time frame Findings….. • Mean removals for all MS = 77 • Selected MS: Max = 660 (2nd = 431) Next step…. • Audit 1 health record with diazepam+++ use

  18. THE PROACTIVE AUDIT Findings: All diazepam accounted for on MAR, but • Dose not always indicated (ROD order) • Initials missing from MAR & Signature Record • Initials & signature of nurse who removed from MS nowhere in the health record • Nurse who signed MAR had no MS activity

  19. THE PROACTIVE AUDIT Now what ??? 1. Meet with Manager • Mystery nurse identified 2. Select other nurses with same EFT, similar rotations and run activity reports (Pyxis OPS) 3. Health record audits (Manager)

  20. THE PROACTIVE AUDIT Findings: 1. Nurse removes: • approx = amt month/month • amt similar to cohort for the specialty area (5 mo; 325 vs 301 tab) 2. Doses removed from MS signed for on MAR but >4 instances drug admin documented on MAR or PN with no corresponding removal from MS 3. No personality or behaviour changes

  21. THE PROACTIVE AUDIT Conclusion We could not find evidence of diversion

  22. THE PROACTIVE AUDIT Some Measurable Costs of the Audit Report generation & analysis 8h Report review (MOPC/DOPC) 2h Chart/MAR review 5h Meetings 5h 20 hours!

  23. THE PROACTIVE AUDIT Or, > $800.00!!

  24. THE PROACTIVE AUDIT - Summary Did our solution work? Pro • Some data on how long an audit would take Cons • Lots of resources required • Not always productive use of resources • Software reporting tools not adequate

  25. What were our solutions ? • Proactive Audit • CII Safe

  26. CII SAFE Jan Beales, Senior Pharmacist

  27. CII SAFE Automated Checks & Balances • Purchasing/Receiving • Inventory • Compounding • Restocking/Returns • Expire, Waste, Recall • Outpatient Rx/Resale • Non- Pyxis Restocking Returns

  28. CII SAFE Purchasing/Receiving Meds • Suggested PO prints weekly • Purchasing done by Purchasing Tech • Med received and scanned into C2 Safe by Narcotic Tech • Invoice reconciled with Acquisition Record by Manager/Pharmacist

  29. CII SAFE Inventory/NarcVault Access • CII Safe controls both accessible and remote stock • All accessible inventory is counted once a week by two narcotic technicians • All remote inventory is counted once a month • All CII Safe Events report prints daily and is reviewed for unusual activity

  30. CII SAFE Compounding • CII Safe automatically reduces bulk inventory and increases unit dose quantity for compounded item • If item not returned to CII Safe a variance is created on the Pyxis vs. CII Safe Report

  31. CII SAFE Medstation Restocking/Returns Restocking • Communication link between MedStn & CII safe • Meds removed from CII safe must be loaded into MedStn or a variance is created Returns • Removals from a MedStn must be returned to the CII Safe or a variance is created Overall • Open Discrepancy & Pyxis vs CII Safe reports are printed daily. • Pyxis vs CII Safe report picks up loads, returns, loads to wrong machines, return bin variances, unload variances • Variances resolved daily by narcotic tech

  32. CII SAFE Expire, Waste, Recall • Med’s returned first, then expired, wasted, or recalled • Meds pending destruction report reconciled with return bin contents • Requires witness to empty return bin

  33. CII SAFE Fill a RX /Sell to Another Pharmacy • The All CII Safe Events report shows “fill a prescription & rx sales”. These are reconciled with signature delivery sheets and RX or sales report • Only Pharmacists & Narc Techs have access to Sell to Another Pharmacy

  34. CII SAFE Non- Pyxis Restocking/Returns • Narcotic Control Record (NCR) generated for non-Pyxis areas • Barcoded for tracking of outstanding forms Restocking Locked Drawer • Signature delivery sheets returned to pharmacy Returns • NCR scanned upon return to pharmacy • Labels & Returns on NCR’s reconciled with signature delivery sheets & return reports • 10% of NCR’s audited for complete information

  35. CII SAFE - Summary Was it a solution? Pros • Automated areas increased tracking and reconciliation of narcotic transactions to 100% • Gained efficiencies in staffing • Expanded services and track more medications (all control drugs) Cons • Generates lots of paper • Only 10% monitoring in non-pyxis areas • Still too many non- pyxis high use narcotic areas

  36. What were our solutions ? • Proactive Audit • CII Safe • Expansion of Pyxis • Psychiatric Hospital • Cart fill wards (ICU, Peds) added Pyxis for narcotics only • Anesthesia use in OR

  37. PYXIS FOR ANESTHESIA Working with the Physicians Monique Yakiwchuk, Pharmacy

  38. DEVICE SET UP • No OR Admitting feed • Set up as Non-Rx, Dr’s as patients • Pharmacy sets user templates

  39. CLINICAL DATA • Add to clinical data category “ENTER NCDUR #” • Narcotic Control Drug Utilization Record (NCDUR) – manual record for the shift. • Pharmacy reconciles removals, returns and wastes associated to that NCDUR Dr’s activity compared to the Pyxis All Station Events Report

  40. RETURN BIN • A double sized drawer reserved for an internal return bin • Accommodates a large quantity of returns • Unloaded daily & reconciled with manual NCDUR / All Station Events Reports

  41. PENDING MEDS • Single dose pockets – no beginning count is required • 12 pocket mini drawers • Anaesthesia Med Station set on “OVERRIDE”

  42. USER SET UP USER ACCESS Approval for access from Head of Anaesthesia Pharmacy Create user ID – ANES + licence number Create Users as Patients – will enable Dr’s to remove under their own name

  43. EDUCATION & TRAINING Pharmacy Education & Support – key to success of TEAM culture Highlights Removals Setting up Kits NCDUR’s Returns Waste Demanding Recounts Document Discrepancies

  44. INVENTORY MANAGEMENT Maintaining accurate Inventory according to usage reports Pharmacy manages all Attention Notices Loads / Refills and Unloads are accurate

  45. DISCREPANCY MANAGEMENT Monitor / Reconcile Discrepancies for ALL End Users Reports Currently Being Used by Pharmacy: DAILY • Manual NCDUR’s compared to Pyxis All Station Events Report – done every morning to reconcile anything not matching • Pyxis vs. CII Safe Compare - reviewed daily; detects pocket refills, unloads, loading errors and potential diversion • All CII Safe Events – reviewed daily; provides an account for all activities

  46. OUTSTANDING DISCREPANCIES Narc Tech to follow up with the end user Pull patient MAR for review /compare to NCDUR’s & OR record Un-resolvable occurrence report completed & documentation given to Senior Pharmacist Follow-up with Head of Anesthesia

  47. PYXIS ANESTHESIA - Summary Was it a solution? Pros • Anesthesia took ownership of their narcotic usage (no more nursing involvement) • Anesthesia workflow has changed with 24 hour access • Ability to track electronically, an area with high narcotic volumes • Significant decreases in outstanding discrepancies • Anesthesia & Pharmacy work as team Cons • Return of manual NCDUR still not 100%

  48. What were our solutions ? • Proactive Audit • CII Safe • Expansion of Pyxis • Psychiatric Hospital • cart fill wards added Pyxis for narcotics only • anesthesia use in OR • Security: Centre- Wide Process

  49. SECURITY • Centre- Wide Process • Standard Employee Application Form for all computer access • Pyxis User Database – maintained by Nursing & Pharmacy • BIOid registration handled by Nurse Educators or Pharmacy • Monthly HR Turnover Report used to process terminations & transfers to non-Pyxis areas • Annual purge of users inactive for > 1 yr • Expiry dates for students are grad dates

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