Policies, Procedures, and Protocols
Having clear policies, procedures, and protocols regarding diversion can go a long way toward prevention and ensuring that staff know when and how to report their suspicions about diversion.
To start, these should state clearly that all staff must comply with state and federal laws and regulations regarding medication handling and security, including but not limited to controlled substances. Policies and procedures also should stress that must report suspected drug diversion, how they should report this, and to who. In addition, they should state that these reports must be done honestly and in good faith.
Policies also should address:
- What reports should include (e.g., witnessed event, suspicious activities or behaviors, self-disclosure of drug diversion, etc.).
- How reporters will be protected from retribution or retaliation.
- What will happen to staff involved in drug diversion (e.g., suspension of employment and/or license, determination, etc.).
- How auditing/surveillance will be handled.
- A “trust but verify” approach regarding controlled substance. handling.
- What will happen to staff who are suspected or proven to be involved in drug diversion.
- What agencies will be notified and how if there is suspected or proven drug diversion.
Even team members, such as nurses, who aren’t prescribers should have a basic knowledge of how medications – particularly controlled substances – are chosen and prescribed. Several prescribing principles are important to understand:
- Residents must be fully assessed to verify the need for pain medications and any decision to prescribe or not prescribe pain medications documented.
- A full medication history for each resident must be taken, and everyone should be screened for substance abuse.
- Opioids should be prescribed only if alternative therapies (including nonpharmacologic interventions) don’t provide results.
- Pain assessment tools should be used to monitor the effectiveness of controlled substances.