CASE STUDY
www.medacist.com
• Receive insights from Senior Vice President of Allied Health, Brian O'Neal, PharmD, Children's
Mercy Kansas City.
• Understand how nursing deals with diversion given unprecedented challenges from Retired
Chief Nurse Officer, Barbara Jacobs, MSN, at Anne Arundel Medical Center.
• Learn about analytics when managing a drug diversion program from Retired Drug Diversion
Surveillance Analyst, Patricia Penland, RN, at Wake Forest Baptist Health.
Diversion threatens patient safety and a hospital's reputation. According to the National Council of
State Boards of Nursing, approximately 15% of healthcare workers struggle with drug dependence
at some point in their careers. Drug diversion among healthcare workers is substantially
underestimated, undetected, and underreported.
And if diversion hasn’t wreaked enough havoc, healthcare professionals have endured upheaval like
never before because of an unprecedented pandemic. Hospitals were already dealing with rising
stress levels, burnout, and staff shortages, which can exacerbate drug diversion.
Diversion poses risks to patients, including inadequate pain relief and exposure to infectious
diseases from contaminated needles and drugs. A healthcare worker’s impaired state also creates
an unsafe environment.
However, solutions and strategies exist to combat it, and hospitals are winning the battle.
A pharmacy executive, chief nurse officer, and drug diversion analyst share insights on the state of
drug diversion and the tools to detect it.
Profile: Senior Vice President of Allied Health, Brian O’Neal, PharmD, Children's Mercy
Kansas City
Q. How does your role relate to preventing diversion and protecting patients?
My responsibility is to ensure we have the resources needed to stop anyone looking to divert drugs.
The likelihood is there. Prevention and detection are a priority for me.
My guidance is to focus on fundamentals, which means consistent quality checks, audits, and
reliance on a strong drug diversion system. But software doesn’t run itself. It takes personnel to
understand how it informs possible problems and how to pull the right data.
Q. Thoughts on the state of drug diversion at hospitals given COVID and staff shortages?
Our hospital, like the industry, is experiencing shortages, especially in pharmacy technicians, due
to the pandemic and job hopping. And how it correlates to diversion is not entirely clear because
we are still dealing with all those issues and current prevalence data. We are dealing with a gap in
scientific evidence.
Q. How does Children’s Mercy Kansas City deal with diversion?
We developed a controlled substance oversight council led by pharmacy and nursing that includes
members from security, human resources, and other hospital departments who meet regularly to
review transactions and approve policies.
DEFYING DRUG DIVERSION
Brian O’Neal, PharmD, MS, FASHP
Senior Vice President
~ Allied Health at Children’s Mercy
Kansas City, MO
Barbara Jacobs, MSN
Retired Chief Nurse Officer
~ Anne Arundel Medical Center,
Annapolis, MD
Patricia Penland, RN
Retired Drug Diversion
Surveillance Analyst
~ Wake Forest Baptist Health,
Winston-Salem, NC
The Pharmacy Executive, Nurse Executive, and Drug Diversion Analyst Tell How
Sponsored by an Educational Grant From Medacist
CASE STUDY
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“
I’m involved with The American Society of Health System Pharmacists (ASHP) and apply their
strategies to diversion prevention program.
Q. What solutions are Children’s Mercy applying today?
I view a successful diversion control solution as having four legs, consisting of:
1. Hardware: The hospital needs an automated dispensing system in various locations, such as
the operating room or nursing units.
2. Software: Diversion systems have come a long way in the last 20 years. Health systems have
benefited from the accuracy of audits and true positives.
3. Human Resource: The system is only as good as the employee who knows how to use and
maximize the capabilities. It benefits significantly from a savvy technician. Make an investment.
4. Culture: Everyone needs to look for warning signs across their system. Red flags exist. And the
staff needs to drive out the thought that it wouldn’t happen here because diversion happens.
Q. What resources are needed to monitor controlled substances?
At Children’s, our pharmacists or pharmacist technicians are responsible for working with the
nursing staff to review the reports. They are the detectives who use the system as their metal
detector to find that needle in the haystack.
Q. With the abundance of data analytics available, how do you use the data for decision-making?
From our system, we are hyper-focused on specific reports. We run aggregated reports on
practice variables, such as the movement or removal of excessive doses. The system flags high
transactions from individuals.
Another critical report for us is the purchase versus receipt. It shows reconciled data from
the wholesaler within our controlled inventory. Our system allows us to watch for ordered
pharmaceuticals that were not logged into the system.
Q. What is the essential data point in detecting diversion?
One of the most significant causes of concern is when a drug is removed and not accounted for
in the system. The starting point to the answer is, “Where should it be?” A successful diversion
program needs a robust reconciliation process.
Q. Based on your expertise, what is your guidance on a monitoring system for drug diversion?
A good starting place is the Guidelines on Preventing Diversion of Controlled Substances from
the American Society of Health-System Pharmacists. Hospital management will receive a robust
blueprint to help focus resources, build capabilities, and implement a collaborative, comprehensive
controlled substance diversion prevention program.
Final Thoughts From Brian
One area that needs more attention is analytics to understand and address drug diversion in retail
and ambulatory pharmacies. Ample transactions and inventory benefit from robust monitoring and
advanced analytics.
Profile: Retired Chief Nurse Officer, Barbara Jacobs, MSN, Anne Arundel Medical Center
Q. How did your role relate to preventing diversion and protecting patients?
I was the chief nurse officer for the 384-bed at Anne Arundel Medical Center, where I guided nursing
care throughout the facility, partnering with many experts in medical specialty areas. The care and
safety of patients were my responsibilities, which included initiatives to stop drug diversion.
Q. Thoughts on the state of drug diversion at hospitals given COVID and staff shortages?
The Pandemic presented a potential for increased diversion, as did the temporary staffing due to
shortages. Nursing is about trusting relationships, and with an influx of travel nurses in the hospital,
nursing leadership didn’t have a history with travel nurses nor the time to get to know them.
Nurses' stress level and diversion have always been my concern, and it accelerated during COVID.
Everyone needs to
look for warning signs
across their system.
Red flags exist.
And the staff needs to
drive out the thought
that it wouldn’t
happen here because
diversion happens.”
Brian O’Neal, PharmD, MS, FASHP
Senior Vice President
~ Allied Health at Children’s Mercy
Kansas City, MO
CASE STUDY
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“
Q. During your tenure, how did Anne Arundel Medical Center deal with diversion?
During my tenure, we developed a multi-disciplinary approach to drug diversion and a standing
committee that manages prevention in multiple ways with input from the pharmacy, nursing,
anesthesia, and human resources.
Q. What solutions did Anne Arundel Medical Center apply?
One of the highest risk areas involves someone signing out medication indicating the patient need and
the person diverting it. We have an auditing tool from our drug diversion system that makes monitoring
the process manageable by frontline leaders. It tracks hundreds of doses given out each day.
Specifically, our sophisticated system looks at the medication situation and reports on what a
person is doing and what is going on with the medication, informing on withdrawal or wasting and
comparing the transaction to others to see it’s different.
Q. What resources are needed to monitor controlled substances?
As the CNO, I felt relief for my staff if a system could free up nurses’ time. A necessary resource is a
system that alleviates the burden of impossible amounts of basic auditing and monitoring.
Q. With the abundance of data analytics available, how do you use the data for decision-making?
The data on waste, withdraws, and returns inform us of the status of medications. The data can
pinpoint if even a small amount was taken or wasted. The analytics tells us if there is more to the
story than the patient refused.
Q. What is the essential data point in detecting diversion?
Being accurate is essential for a possible diversion case, so we look to the analytics to provide
evidence. I received a monthly report on discrepancies and unresolved items to update me on how
we were doing with the practice.
Q. Based on your expertise, what is your guidance on a monitoring system for drug diversion?
My guidance is to establish a multi-disciplinary committee that meets regularly to review protocols
and drug diversion performance. I advocate for a strong relationship with human resources
because they can guide you with communications and support if a diversion problem occurs.
Final Thoughts From Barbara
It’s about the patient, and diversion could mean a patient doesn’t get the needed medication, which
is against the nursing mission.
An allegation requires substantial diligence. Diversion is a felony, so getting it right is necessary for
the patient, employee, and hospital.
We can’t lose sight of fairness and empathy for an employee. Helping an employee with a drug
problem is also a responsibility.
Diversion requires objectivity and analytics. Concrete evidence is a must in any investigation.
We sent a strong message to employees and traveling nurses that this hospital prioritizes diversion
prevention and that this is not the place if you want to divert.
Profile: Retired Drug Diversion Surveillance Analyst, Patricia Penland, RN, Wake Forest
Baptist Health
Q. How did your role relate to preventing diversion and protecting patients?
When I started as the surveillance analyst in 2019, it was to support the head of pharmacy with the new
Drug Diversion Prevention and Response Team. Our initial processes for surveillance and investigation
were very manual, requiring drilling down through pages of reports. It was very labor intensive.
One of my most crucial roles entailed educating employees about preventing drug diversion and
collaborating with nursing leadership on all aspects of the program.
Q. Thoughts on the state of drug diversion at hospitals given COVID and staff shortages?
When we rolled out the education component of our diversion program, there was still a surprise
from the staff that drug diversion was happening. We heard, “people do that?” So, some staff
It’s about the patient,
and diversion could
mean a patient
doesn’t get the needed
medication, which is
against the nursing
mission. We sent
a strong message
to employees and
traveling nurses
that this hospital
prioritizes diversion
prevention and that
this is not the place if
you want to divert.”
Barbara Jacobs, MSN
Retired Chief Nurse Officer
~ Anne Arundel Medical Center,
Annapolis, MD
CASE STUDY
“
didn’t know it was happening. And they didn’t know what to look for or how to address it if they
suspected a case.
Diversion wasn’t top of mind at the hospital. It was my job to raise awareness that it is still an
issue. We put diversion detection at the forefront of our staff education program.
Q. How did Wake Forest Baptist Health deal with diversion?
While I was the diversion analyst, the chief nursing, pharmacy, and legal officers led an executive
oversight committee on diversion. They also bring in communications and compliance to
advise on policies and situations. This committee established the Drug Diversion Prevention
and Response Team, which regularly informs committee members about the state of diversion,
current issues, and possible diversions.
The team continually mitigates diversion risk by analyzing clinical practice workflows because
someone who will divert will find weaknesses, permitting the possibility of diverting throughout
the system.
Q. What solutions are Wake Forest Baptist Health applying? Are they successful?
As an analyst, technology that allowed me to pull documents into one system and validate the
data make my job easier and more successful.
Q. What resources are needed to monitor diversion of controlled substances?
Resource need depends on the area in the hospital. Monitoring med surge is different than reviewing
controlled substances in general nursing. If you must put a case together, you have to have tools
and resources that substantiate the case because we don’t want to accuse people falsely.
Q. With the abundance of data analytics available today, how do you use the data to make an
informed decision?
Data allows us to identify trends and pinpoint issues quickly. Analytics is a needed piece of the
puzzle when putting a case together. It’s a big benefit to having analytics.
Q. What is the essential data point to detect diversion?
One of the easiest and earliest is to focus on where the highest level of dispensing is occurring.
A good start is examining the top five or ten users dispensing narcotics and why they are
dispensing. Is it because they work in oncology or the ICU where high usage occurs? It’s about
trust and verification.
Q. Based on your expertise, what is your guidance on a monitoring system for drug diversion?
This work is not trying to “catch” someone but rather mitigate a problem that could potentially
harm the patient. People don’t want to discuss diversion, but you must discuss it.
Final Thoughts From Patricia
Getting executive buy-in from the start was critical for the diversion prevention team. Leadership
put an organized structure around addressing diversion, making it an organizational priority.
This work is not
trying to 'catch'
someone but rather
mitigate a problem
that could potentially
harm the patient.
People don’t want to
discuss diversion, but
you must discuss it.”
Patricia Penland, RN
Retired Drug Diversion
Surveillance Analyst
~ Wake Forest Baptist Health,
Winston-Salem, NC