Controlled Substance Diversion Prevention is a Key Element in Pharmacy and Hospital Compliance

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Controlled Substance Diversion Prevention is a Key Element in Pharmacy and Hospital Compliance

Hospital pharmacists play a key role in effective and safe medication use. Most young pharmacists who begin their careers in facilities look forward to the role of improving patient care. However, many of these young professionals discover that they also may get involved with compliance activities, including monitoring and auditing controlled substances in the pharmacy and throughout the facility. This part of the job can be time consuming and requires significant attention to detail, something that new hospital pharmacists may not be aware of early on.

Chris Beebe, Senior Vice President of Compliance and Regulatory Services at CPS, says that he continues to share a passion for patient care that all pharmacists have. But decades of experience in pharmacy management have given him another perspective that he thinks newcomers must consider.

“Newer pharmacists are focused on the patient treatment aspect of pharmacy, which is great,” said Beebe. “But what keeps pharmacy directors up at night, in many cases, are regulatory issues. These include monitoring controlled substances to prevent drug diversion.”

Beebe works for CPS, the leading provider of hospital pharmacy management in the United States. He develops policies and best practice recommendations to help hospitals meet and exceed medication-related compliance standards, including controlled substance practices. His experience is grounded in years of work as a pharmacist, a pharmacy director, then as regional manager for a large hospital system, before joining CPS in his current role.

“One of the hospitals that I managed within my old system had a major diversion case that came from within the pharmacy,” recalled Beebe. “It ultimately led to DEA fines and sanctions for the facility.”
In further investigations, the system team discovered a gap in pharmacy ordering and receiving processes, which an employee exploited.

“We already had processes in place to detect drug diversion,” said Beebe. “I began asking questions such as, are there gaps in the pharmacy workflow process? Where in the system do these gaps exist? What about on patient care units? I started focusing on compliance for the system, including controlled substance diversion prevention.”

Using the lessons learned in his previous company, Beebe has worked with CPS hospital pharmacies and consulting clients to help them detect and combat drug diversion. According to Beebe, these practices, whether they are required or not, are meant to go above and beyond expectations. Being proactive when developing processes for auditing and monitoring helps catch drug diverters and improves practice efficiency.

When asked what some of the top issues he sees in pharmacies and their controlled substance practices, Beebe indicated the following:

  1. Controlled substance inventories. It’s important that hospital pharmacies conduct regular inventories to validate that all controlled substances are accounted for. Beebe and his team follow up with hospital pharmacies regularly to ensure they are performing inventory counts at the prescribed intervals.
  2. Separation of duties. Pharmacy staff who order controlled substances should not be the same ones receiving, processing the invoices, and putting the drugs away. “We have policies and best practices that describe the separation of duties between ordering and receiving,” said Beebe. “Even in hospitals with smaller staffs, we find ways to employ these policies.”
  3. Regular auditing. This may be time consuming, especially if it’s manual, but it is the most effective way to monitor controlled substance activities and detect potential drug diversion. This includes auditing pharmacy transactions as well as those on patient care units.

“A drug diversion event could result in a hospital ending up on the front page of the paper,” said Beebe. “Having processes in place to monitor for drug diversion events really can make lives easier for pharmacy directors when it comes to inspection time.”

According to Beebe, deploying these processes and protocols can also help with patient safety and protect a hospital’s reputation. Although this specialization in regulatory and compliance was not what he may have envisioned coming out of pharmacy school in 1993, Beebe is grateful for his career and the change he and his team are creating at hundreds of hospitals nationwide.

“In 1993, the robust software like we have today would have been helpful to replace the time consuming, manual processes for auditing, taking the human error out of it,” said Beebe. “But when I get to explain why we’re implementing specific practices and why details matter, that usually triggers the light bulb to go on for hospital pharmacists.”

This article first appeared in Anigent’s December 2021 DDWatch and is reprinted with permission.


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