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