Monitoring anesthesia usage controlled substances.

[deleted126335]

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Anesthesiologist here.
I am looking for some data on what constitutes "best practice" for controlled substance accounting/monitoring for anesthesia personnel. We use a controlled substance log that is randomly reviewed with the anesthesia record coupled with "witness wasting". This is obviously easily defeatable. Turning in drawn up but unused narcotics to pharmacy personnel for random assay has been suggested. 99% of the discrepancies between controlled substances logs and anesthesia records are sloppy accounting or *****s who just can't add. I have little doubt that those who are diverting make doubly sure that the paperwork is correct. What are folks who are confident in their process doing?

 

[Digsbe]

I don't know how applicable this would be for anesthesiology, but I rotated in a hospital where to gain access to a controlled substance on the floor someone needed a witness that would have to use a biometric scan (fingerprint) before a medication could be accessed. If a patient was prescribed oxycodone and the nurse went to retrieve it from the Pixis they would have to have a witness (usually another nurse) scan off on things as well before they could get the medication. They had ways of electronically checking the logs to see who was getting more controlled substances and whatnot and the pharmacists would check them on a routine basis. I think an electronic system may be beneficial if you are having human errors with paper logs where people are editing them or putting in information sloppily. At the hospital pretty much all of the drugs were stored in a Pixis machine or in a Pixis linked cabinet and everything that was done was recorded electronically requiring bioscans to access things (might be an expensive solution though). Many of the diversions I've heard of were people recording that they took out X number of a dosage form in accordance with orders for a patient but took more than what they should using the rest for themselves. Other times with administration some would only give patients partial doses (usually seniors or those not in their right mind) and kept the rest for themselves. In the logs they showed that they took out the right amount and the counts would be right but at the administration side of things the patient got less. This usually happened with oral tablet medications where orders were to give 1-2 tablets as needed or something like that with the nurse only giving 1 or half a tablet and the patient not knowing any better.

I'm unsure of any published papers detailing a "best practice" model though for controlled substance accountability/monitoring.

 

[MackandBlues]

in our OR pharmacy we do the random assay testing. but fentanyl reads like water at 0% so that one's easily faked. We have the anesthesia records given to us that says what's given and it better match what they are turning in to the OR pharmacy including the waste drawn up in syringes. I think the best way is to use pyxis for anesthesia personnel.

 

[Sparda29]

Currently we dispense anesthesia kits that contain 10 Fentanyl (200 mcg vials), 1 Ketamine vial, 10 Midazolam vials, and 2 Hydromorphone 2mg/ml. So we have a sheet that goes with the kit where the anesthesiologists fill out what they used for which patient. Except wastes don't come back to pharmacy, we expect them to waste it in the OR. Soon we're gonna have Pyxis in the OR and that will be the end of that.

 

[RogerWilco]

One option is to obtain automated dispensing cabinets (ADC) like Pyxis or Omnicell which require BIO-ID to access. The ADC should be set up to dispense unit of use (1 vial, carpuject, etc). Waste can be recorded at the machine and setup to require a witness. Someone (most likley from pharmacy) should be assigned to audit the Anesthesia records and the Omnicell/Pyxis records reconciling use and wastage. Those who pulled and used the medication (anesthesiologist or nurse anesthestist) should also be the one to waste the medication and document using another licensed practitioner who acts as a witness via tha automation and BIO-ID/ passcode.

Discrepencies need to be addressed by those who pulled and wasted the med. This is where you need strong leadership to hold staff accountable and implement consequences for recurrences by the same individuals.

The process does not prevent collusion by two individuals but patterns will eventually arise.

 

[PharMed2016]

It's interesting that you should bring up this very subject. When I shadowed an anesthesiologist in the OR, I was a little surprised at how CS were handled and the ease by which they could've been diverted (Pyxis included). We can put the above system in place but how much CS administered/documented can be falsified easily.

 

[RogerWilco]

True - some level of trust come down to the end user...pharmacist, dentist, MD etc. If one thinks hard enough there is always a way to circumvent the system.

 

[mustang sally]

One option is to obtain automated dispensing cabinets (ADC) like Pyxis or Omnicell which require BIO-ID to access. The ADC should be set up to dispense unit of use (1 vial, carpuject, etc). Waste can be recorded at the machine and setup to require a witness. Someone (most likley from pharmacy) should be assigned to audit the Anesthesia records and the Omnicell/Pyxis records reconciling use and wastage. Those who pulled and used the medication (anesthesiologist or nurse anesthestist) should also be the one to waste the medication and document using another licensed practitioner who acts as a witness via tha automation and BIO-ID/ passcode.

Discrepencies need to be addressed by those who pulled and wasted the med. This is where you need strong leadership to hold staff accountable and implement consequences for recurrences by the same individuals.

The process does not prevent collusion by two individuals but patterns will eventually arise.

This is what we do. Pharmacy audits the anesthesia records weekly. Obviously it's not a perfect system, but we have caught some mishandling of narcotics (not necessarily diversion, but rather certain anesthesia personnel clearly not following the policies, for whatever reason). As stated above, this does require strong leadership to address these circumstances.