Controlled Substance Documentation Education

1. Controlled Substance Documentation Education All staff members who administer controlled substance medications

2. Objectives • Describe what constitutes diversion • Identify appropriate timeliness of the administration of controlled substances • Review the elements for documentation of obtaining,  administrating, or wasting of controlled substances. • List the steps in resolving discrepancies  

3. Possible diversion • Controlled Substance use and diversion among nurses is the #1 reason named by nursing boards for taking disciplinary action • It can also be a concern for other staff members who administer controlled substances • It is estimated that 12-16 % of health care professionals will be addicted to a controlled substance at some point in their career (1) • Charting errors and omissions can be a red flag when a staff member is diverting controlled substance medications

4. Cost of Diversion • Reduced/lost productivity • Loss of employment • Impact the health and safety of others (1) • Impaired staff members • Decreased quality of patient care • Increased length of patient stay • Potential patient injury

5. Diversion • 4 broad categories of diversion • Simple theft- removing CS without documenting removal in the PYXIS or taking out a larger dose than needed and diverting the remainder • Theft by substitution- the narcotic is removed from a tubex or vial and then is replaced with saline, water or another liquid • Theft charting- CS is documented as given but was diverted and the patient did not receive the medication • Under-medicating the patient- withholding a portion of the ordered dose from the patient and diverting that portion (2)

6. You may think that Diversion does not happen at the VA…it does… The following are cases from VA facilities: • “A VA nurse was sentenced to 15 days incarceration, 36 months probation and was ordered to pay $710 in restitution to the VA. The OIG and VA police investigation revealed that the nurse used his position to gain access to the identities of patients no longer under his care to access a VA automated dispensing device, falsely recording that the controlled substances were for these patients. He then self administered the controlled substances to include Fentanyl and Midazolam, while on duty and providing care to Veterans (3) • A former VA ICU nurse who was indicted for diversion of controlled substances after an OIG and VA police investigation revealed that he obtained Hydromorphone and falsified controlled substance records to conceal his theft of the drug. This case was initiated following an internal VA analysis that showed a high frequency of PYXIS system overrides performed by this nurse compared to the other nurses on the ward.(3) • A former VA nurse entered into a 12 month agreement for pretrial diversion for obtaining controlled substances by deception. An OIG and VA police investigation revealed that the nurse stole VA controlled substances from the PYXIS. She admitted to diverting approximately 2-3 Hydrocodone and/or Oxycodone pills per shift for personal use. (3) • A former VA RN was sentenced to 3 years supervised probation and 200 hours community service after pleading guilty to obtaining controlled substances by fraud. An OIG and VA police investigation revealed that on approximately 24 occasions in a 4 month period, the nurse stole Morphine, Hydrocodone and Oxycodone, that were intended for VA patients(3)

7. Documentation of controlled substances • It is important to document controlled substance medication administration and waste, it protects the staff member and patient. • Proper controlled substance administration documentation • Facilitates good communication • Promotes good patient care • Meets professional and legal standards • If it is not documented then it was not given.

8. Documentation ..continued • Proper documentation communicates when the medication was given and how much was administered • Controlled substance medications need to be documented within 1 hour of removal from the PYXIS • Waste needs to be documented at the time of removal in the PYXIS with a witness • If the medication is used in conjunction with a procedure (ie. Colonoscopy) then the waste will be completed and documented immediately after the completion of the procedure

9. Witnessing a waste of controlled substances • If you are the witness of controlled substance waste • You are signing that youobserved the medication waste according to policy • Make sure that you are watching the staff member actually waste the controlled substance

10. Process to waste controlled substances • Waste controlled substance prior to leaving medication room when possible • Oral tablets and PCA cassettes should be placed in the sharps container • Controlled substance vial • The full amount should be withdrawn into a syringe • Excess should be squirted onto a cotton ball or 2x2 • Dispose of in the sharps container • Prefilled syringe • Partial dose is to be given • Excess amount is to be squirted on a cotton ball or 2x2 • Dispose of in the sharps container

11. Wasting of controlled substances • If the patient refuses the controlled substance after removal from the PYXIS • Return to the PYXIS • Or waste in the PYXIS with a witness within 1 hour of removal • Fentanyl Patches are to be folded in half with the active part sealed and disposed of in sharps container.

12. Documentation of controlled substances • If a controlled substance is not documented as administered or if a partial dose is wasted and not documented • It can be considered a drug DIVERSION • Potentially the staff member would submit to a urine test • Possible disciplinary action

13. Diversion Prevention • Every employee is responsible for preventing the diversion of controlled substances • Never share your PYXIS access code with anyone • Prior to administering controlled substances • Check for the integrity of the package/syringe • Look for signs of tampering • Ensure that liquids have a normal color, odor and consistency • Tablet packaging or tablet is not damaged • If you suspect tampering • Do not administer to the patient • Contact the pharmacy, nurse manager/charge nurse immediately • Remove the medication and turn it over to your supervisor or pharmacy (4)

14. Signs of Potential Diversion • Staff documenting more PRN medications than any other staff member • Patient off unit at time dose is documented • Dose removed from the PYXIS but not documented in BCMA/CPRS • Inconsistent documentation of controlled substances • Nurse volunteers to administer controlled substance to another nurse’s patient • Staff say they were to busy or forgot to obtain a witness to discard a controlled substance • Staff signing out a larger dose than was ordered

15. Signs of Potential Diversion • Staff claim an access code was shared with another staff member (if not using Bio ID) • Controlled substance withdrawal times do not correspond to administration times • Patients report that the pain medication ordered does not control their pain during a particular staff’s shift • Inaccuracies of controlled substance counts during a particular staff’s shift • Controlled substance medications signed out for a patient who has no order for them (5)

16. Signs of Potential Diversion • Signing out more controlled substances than co-workers • Frequent reporting of medication spills or other non-administered partial doses • Failure to obtain witness to waste controlled substance • Staff waiting until no one is around to access the PYXIS • Disappearing into the bathroom after opening the PYXIS • Defensiveness when questioned about medication errors(5)

17. Signs of Potential Diversion • Consistently coming to work early and staying late. • Volunteering to work with patients who receive regular doses of large amounts of pain medication • Observation of any combination of these behaviors with increasing regularity over a period of weeks or months • Changes in the staff members job performance over time with no apparent cause • Inability of staff to take or provide feedback(5)

18. Signs of Potential Diversion • Progressive deterioration in personal appearance and hygiene • Sloppy documentation • Absenteeism-excessive number of sick days • Confusion, memory loss • Mood swings, change in behavior, personal & professional isolation (6)

19. Signs of Potential Diversion • Requesting frequent PYXIS refills from pharmacy for certain controlled substances • Orders placed for patients who have been discharged • Frequently forgetting, or too busy to document controlled substance administration • Administers drugs IM or IV when other staff give PO to the same patient • Use of smaller tablets of medication to give prescribed dose (two 30 mg Codeine tablets instead of one 60 mg tablet)(7)

20. Signs Of potential diversion • Controlled substances that disappear on the staff members shift then reappear later in the unit • Variances between the medication record and physicians order, i.e. frequency • Initiating a physicians order to change the frequency of a controlled substance order(4) • Frequent PYXIS overriding of controlled substances

21. Documentation • The controlled substance coordinator and managers can track controlled substances via Pandora, a computer software program • Trend by controlled substance(s) • Trend by staff member(s) • Investigate trends for possible diversion • Possible disciplinary actions for confirmed diversion

22. Do the right thing • Protect yourself and your patient through proper controlled substance documentation • Remember to document the administration of controlled substances within 1 hour of removal from the PYXIS • Document the waste of controlled substances at the time of removal from the PYXIS or immediately after a procedure • If you suspect diversion, or think a coworker may be diverting, notify your supervisor immediately

23. References 1. Jorgeson, J. Controlled Substance Diversion Tales From the Front [powerpoint]. Available from: http://www.pharmacyonesource.com/images/veriform/DrugDiversion.pdf 2. Carlson GM, Castile JA, Janousek JP. Guidelines for the prevention and detection of controlled substance diversion. Hosp Pharm. 1988 Dec;23(12):1057-9. 3. Department of Veteran Affairs. Controlled Substance Inspection Certification. Available from: VA Training Management System [Online]. 4. CNA. Intervention: Risk Management Strategies for Impaired Nurses [Internet]. Chicago: CNA HealthPro. Available from: http://www.cna.com/vcm_content/CNA/internet/Static%20File%20for%20Download/Risk%20Control/Medical%20Services/Intervention_Risk_Mgmt%20Strategies_for_Impaired_Nurses.pdf . 5. National Council of State Board of Nursing. Substance Use Disorder in Nursing: A Resource Manual and Guidelines for Alternative and Disciplinary Monitoring Programs. 2011. Available from: https://www.ncsbn.org/SUDN_10.pdf 6. Barreras J. Drug diversion in healthcare facilities [Internet]. 2010 Oct. 11. Available from: http://www.surgistrategies.com/articles/2010/10/drug-diversion-in-healthcare-facilities.aspx  7. Colorado Board of Nursing. Resource Manual: The Impaired Nurse. Available from: http://www.dora.state.co.us/nursing/complaints/DiversionResourceManual.pdf 8.HPM 00-13; Inspection of Controlled Substances - VHA Handbook 1108.02

24. Questions? Thank You