Background: Controlled substances (CS) diversion in health systems can lead to serious patient safety issues, harm to the diverter, and significant liability risk to the organization. Diversion driven by addiction puts patients at risk of harm.
Purpose: The first purpose of this project is threefold: One was to increase awareness of best practices surrounding controlled substance handling. The second purpose of the project was to develop and use auditing tools to maintain strict monitoring of best practices. The third purpose was to evaluate the effectiveness of the auditing tools in following medication administration best practices.
Methods: A multi-disciplinary team was developed that included the CNO, director and manager of pharmacy, and the manager of surgical care. The team reviewed current best practices and Advocate Aurora policies in the regulation, monitoring, and handling of controlled substances. Education on practice expectations were rolled out to all team members and leadership who administer and monitor for CS usage. Tools were developed to support monitoring of CS. Reporting structures were put in place for follow up on critical components and timely investigation for deviation of best practice. With the use of technology, the team within the organization was able to collaborate on vital pieces of information for the project that expanded to the patient service area (PSA).
Data collected: Baseline knowledge assessment was obtained for team members and nurse leaders. Baseline data was obtained for unwitnessed CS waste using pyxis generated reports. Discrepancies generated by mismatches of CS from the order, pyxis pull to administration, including documentation was carefully monitored.
Results: 100% of CS handling team members and nurse leaders were educated on best practices. 100% of nurse leaders and patient care leaders (PCLS) were educated on the various monitoring methods for CS. There was a noted 65% decrease in unwitnessed waste of controlled substances. There was a 18% reduction of CS mismatches from pyxis pulls to administration.
Discussion: As demonstrated, with education of CS handling and administration best practices, an organization can decrease its liability for risk of harm. With enhanced monitoring and timely follow up for deviation from best practices, corrections can be addressed to prevent serious patient harm.