Safety Advisory by The Joint Commission Issued on Drug Diversion and Impaired Healthcare Workers
A new advisory from The Joint Commission—an independent, nonprofit healthcare standards-setting and accrediting body—is urging healthcare providers to develop “comprehensive controlled substances diversion prevention programs to aid in detecting and preventing drug diversion.”
This advisory is a response to the statistical data provided by the US Substance Abuse and Mental Health Services Administration and the American Nurses Association reporting that an estimated 10 percent of healthcare workers are abusing drugs.
The advisory identified drug diversion patterns, trends, and safety actions, and pinpointed “three essential components healthcare organizations should consider when dealing with drug diversion—prevention, detection and response.” The recommended safety responses for each area include:
- Prevention: Healthcare facilities are required to have systems to guard against theft and diversion of controlled substances.
- Detection: Healthcare facilities must initiate systems to facilitate early detection, such as video monitoring of high-risk areas, active monitoring of pharmacy and dispensing record data, and teaching staff to be aware of and alert to common behaviors and other signs of potential diversion activity.
- Response: Appropriate response for staff should be “see something, say something.” At the institutional level, appropriate responses include establishing a just culture in which reporting drug diversion is encouraged.
The Quick Safety is available on The Joint Commission website at:
https://www.jointcommission.org/
It may be reproduced if credited to The Joint Commission.
Compliance Perspective
Failure to guard against theft and diversion of controlled substances may result in residents experiencing significant medical errors and substandard quality of care in controlling their medical conditions, i.e., pain, behaviors, and infections. This may be considered provision of fraudulent services and violate the False Claims Act.
Discussion Points:
- Review policies and procedures for prevention theft and diversion of controlled substances.
- Train staff to strictly follow protocols for medication reconciliation and reporting of any suspected theft or diversion.
- Periodically audit for medication errors by interviewing residents about the control of their pain and interviewing staff regarding changes in residents’ behaviors and condition.
