Hospitals have been struggling with loss or theft of medication for a long time, and until recently, data and solutions have been elusive. Finally, there is a new tool to help hospitals’ address this sensitive and complex problem.
“Preventing drug diversion is complex,” says Dr. Patricia Trbovich, who is the Badeau Family Research Chair in Patient Safety and Quality Improvement at North York General Hospital (NYGH) and an Associate Professor at the Institute of Health Policy, Management and Evaluation at the University of Toronto. She is one of the leads behind a new study (funded by Canadian Institutes of Health Research), which created a Canadian risk assessment tool for hospitals to identify diversion risks and provides guidance on how to address them. “Many hospitals may treat diversion as a ‘people-problem’, but improving the design of the overall medication system is critical. Without well integrated policies, technology, and practices, hospitals won’t have the understanding they need to detect and prevent diversion.”
There is another benefit to taking a system-based approach. “Standardizing the policies and data infrastructure around medication records leads to more equitable and effective approaches to identifying when and how controlled drugs go missing,” says Trbovich. For example, ambiguous hospital policy around record-keeping, lack of strong security measures, and haphazard investigation procedures can perpetuate biases or exacerbate existing inequities and discrimination, and negatively influence how hospitals and staff respond to instances of diversion. Investigations must be supported by confidential and impartial audit data to overcome bias and inequity in decision making.
With the backdrop of the continuing opioid crisis and widespread recognition that diversion is under-detected and under-reported, hospitals must urgently attend to this issue. Diversion deprives patients of needed pain relief, jeopardizes staff and patients, and risks spreading new infections from non-sterile syringes. Hospitals face costly internal investigations when diversion occurs, negative publicity, and litigation.
Healthcare workers are not immune to substance use disorders, and identifying staff in need of treatment is another reason to detect diversion. Dr. Darryl Gebien, an emergency medicine physician, who has publicly shared his story of forging prescriptions while addicted notes, “A person doesn’t choose to blow their life up with an opioid addiction. It grows from initial subtle use in the beginning, and then to escalating doses and risky behaviour.”
Gebien was caught, filed for bankruptcy and incarcerated, but has now recovered and returned to practice. He advocates for change in the system, “I could have been helped much sooner. There’s a lot of good we can do help people early. We can’t arrest our way out of this problem.”
Dr. Trbovich partnered with Dr. Michael Hamilton to create the free online tool, with early designs reviewed by the Ontario Branch of the Canadian Society of Hospital Pharmacists. Dr. Hamilton is the Medical Director of the Institute for Safe Medication Practices Canada (ISMP Canada) an independent, not-for-profit organization that advances medication safety. “Currently the Pan-Canadian Diversion Risk Assessment Tool is free and open to any Canadian acute care facility,” Hamilton explains.
Hospitals register for the tool by emailing mssa@ismpcanada.ca and the tool itself can be accessed here: https://mssa.ismp-canada.org/cdn-diversion. Hamilton adds, “The aggregated anonymized results from the tool will be hugely beneficial as there is no national snapshot of diversion risks in Canadian hospitals, and hospitals will be able to benchmark against themselves against the aggregate.”
Over 50 hospitals have signed up so far, and early feedback has been positive. The tool takes about 2 hours to complete. “We have found it very effective in helping us focus our resources on those things that have the greatest impact,” says Edith Rolko, NYGH Pharmacy Director.
“We have rolled it out to all UHN sites,” says Lori Taylor, Manager of Professional Practice Lead at University Health Network “We think it will help us compare practices and share best practices internally. It is also helping us prepare for future Accreditation reviews.”
While hospitals will see their scores immediately to support local improvements, Trbovich and Hamilton are looking forward to analyzing the aggregated results starting July 2023. They plan to share and use this information to propel innovation and national system changes so we can finally have data-driven solutions to this long-standing and widespread issue.
By Mark Fan
Mark Fan is the research manager with humanera, an applied human factors research team based at North York General Hospital and University of Toronto.