Accreditation

Tips for averting drug diversion

Accreditation Connection, March 20, 2006

Tips for averting drug diversion

 

Preventing drug diversion involves examining a hospital's overall system, not just individual employees. JCAHO standard MM.4.80 requires hospitals to have processes in place to address diversion prevention, and account for unused, expired or returned medications.

 

Saint Barnabas Medical Center in Livingston, NJ uses Pyxis automated dispensing units and software to help track medications used in the hospital. The system allows the hospital to run reports by user to see who removes which drugs, how many patients a nurse may have, and how many doses staff remove. Staff count narcotics every day so if there is a discrepancy, they need only look back at the previous 24 hours.

 

Keeping a discrepancy monitoring log allows you to show the JCAHO and state agencies how you track narcotic discrepancies.

 

Source: Briefings on JCAHO (published by HC Pro), March 2006              

 

 

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