Tips for preventing staff, physician drug abuse
The type of drug theft that was central to the anesthesiologist’s case in Pennsylvania is the hardest type to prevent and detect, says Jeffrey Driver, ARM, corporate risk manager for Children’s Hospital and Health Center in San Diego.
In addition to stealing drugs right off the shelf and faking paperwork, the anesthesiologist consumed drugs that were obtained legitimately for his patients. Instead of giving them the drugs, he administered extremely diluted saline.
"They’ve obtained the drugs in all the right ways, so the only way to catch this type of diversion is to actually see them preparing the solutions in the wrong way," Driver notes. "It’s a very common way for anesthesiologists to steal narcotics. They often just administer plain saline to the patient and no one knows."
Another twist on that technique is to simply claim that patients need more painkillers or sedatives than they really do. The anesthesiologist can obtain more drugs, document their use, then give the patient a portion of the total amount. The anesthesiologist keeps the rest for personal use, and the patient may receive all or nearly all of the amount needed. The higher drug dosage is attributed to physiological factors in the patient.
Many hospitals also require that any unused medication be thrown out instead of returned to the pharmacy or used on the next patient. That makes it simple for an anesthesiologist to obtain more than necessary and keep the rest.
Comprehensive approach works best
Catching individual instances of drug theft can be extremely difficult, but a comprehensive program can be successful in ferreting out drug thieves and drug abusers. Driver recommends taking these steps:
• Educate all employees about the warning signs.
One of the best ways to head off problems is to encourage other employees and physicians to lookout for suspicious behavior. Inservice programs should provide them with a list of common traits in drug abusing employees and encourage staffers to report suspicions. At Children’s Hospital and Health Center, staffers are given a list of red flags that could signal drug abuse. (See story, at right, for more tips on spotting health care providers who are abusing drugs.)
You also must provide a way for employees to report suspicions confidentially. For physicians, most states allow confidential reporting through the peer review system.
Information about warning signs should be coupled with advice on how providers can volunteer for help with their own drug problems, advises Denny Thomas, director of risk management for St. Joseph’s Hospital in Marshfield, WI. A good education program sometimes can show health care providers that, as they suspected, they do indeed have a problem.
• Test all employees and non-employees for drug use.
The testing of hospital employees for drug use is common, but Driver points out that more hospitals are instituting procedures for testing non-employee physicians and others. His facility has a policy requiring pre-employment (or pre-privileging) and for-cause drug testing. Anyone can be required to submit to a drug test if hospital administrators have reason to suspect drug abuse. Reasons may include practice errors or suspicions reported by others at the facility, Driver says.
Physicians have not protested their inclusion in the drug testing policy. Thomas also recommends pre-employment and for-cause drug testing of employees and non-employee physicians. Some facilities have included physicians in random drug testing programs, but Thomas says he is uncomfortable with requiring physicians to be tested without cause once they are credentialed.
• Conduct criminal background checks.
It is highly unlikely that the Pennsylvania hospital would have hired the drug-abusing anesthesiologist if administrators had known he had an extensive criminal record that included drug possession and kidnaping.
Driver’s facility routinely checks the criminal background of all employees, but not physicians. "But hearing that the anesthesiologist in that case had such a background, I’ll think about adding a criminal background check to our credentialing process," he says. "I would be shocked to hear that one of our doctors had a record of major crimes in four states."
Thomas, on the other hand, says firmly that physicians should undergo a criminal background check as part of the credentialing process.
• Tightly control the flow of drugs.
Anesthesiologists and others always will have special access to drugs, but your facility should control the access as much as possible. Instead of a stock cabinet with wide access, the facility should have a system that requires a close accounting of all drugs removed for patient use. In particular, staffers and physicians should be very limited in the manner and amount of drugs they are allowed to carry on their person. Consult with your hospital’s pharmacy director for ideas on procedural ways to limit access and decrease the chance of drug diversion.
• Reserve the right to investigate suspicions thoroughly.
Driver’s facility has policies designed to allow administrators to thoroughly investigate any suspicions of illegal activity, including drug abuse. All employees and physicians are notified from the outset that there are no "private" areas on hospital property. That means that administrators are free to search anyone’s locker, desk, or work area. The policy also makes clear that electronic mail in the hospital’s computer system belongs to the hospital and can be searched at any time.
In addition, all employees are warned that the hospital reserves the right to use concealed videotaping in most areas of the hospital. Concealed videotaping is not be used in intimate areas such as bathrooms and changing rooms, but it can be used to monitor activities in a drug storage area, for instance.
"You try to put together a lot of clues, and then you start an investigation," Driver explains. "We call it a quiet investigation’ at first, while we look for trends in practice, incidents with patients, complaints and calls to the hospital, and talks with staff members. If our suspicion grows, we may step up the investigation and bring in a private investigator to work on the premises."
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