NARCOTIC DIVERSION
THE HSC EXPERIENCE
Jan Beales, Pharmacy
Linda Carroll, Pharmacy
Roberta Lowry, Nursing
Monique Yakiwchuk, Pharmacy
Pyxis Usergroup Meeting
September 23-25, 2008
OVERVIEW
 Who are we?
 What were our challenges?
 What were our solutions?
 What are the current barriers?
 What are our future plans?
 What is our wish list?
Pyxis Usergroup Meeting
September 23-25, 2008
Who are we?
• 850 bed tertiary bed teaching hospital
• Catchment area- Province of MB and northwestern
Ontario
• Hospital footprint 32 acres
• HSC Staff – Total 7,000
– 3,800 nursing staff
– 150 pharmacy staff
– 90 anesthesiologists
Pyxis Usergroup Meeting
September 23-25, 2008
Who are we?
• Unit Dose Distribution- includes both cart fill
and Pyxis/CIVA
• Pyxis Operations – Pharmacy/Nursing
Operations Committee
• Pyxis Equipment (46 wards)
–
–
–
–
62 Pyxis Medstations
41 Pyxis Auxiliary cabinets
1 tower
CII Safe
Pyxis Usergroup Meeting
September 23-25, 2008
OVERVIEW
 Who are we?
 What were our challenges?
Pyxis Usergroup Meeting
September 23-25, 2008
NARCOTIC DIVERSION
Pyxis Usergroup Meeting
September 23-25, 2008
What were our challenges?
•
2001 completely manual narcotic system
•
2002 Pyxis on 20 Adult patient care wards
– many areas still a manual narcotic system & a manual narcotic
vault
•
High volumes of narcotics
– 167,000 T3 tablets/year
– 103,000 morphine 10mg/ml amps/year
– 20,000 fentanyl 100mcg/2mL/year
•
Security –over 4,000 staff in database– difficult to maintain
•
Reporting tool deficiencies
•
Limited resources for proactive surveillance
Pyxis Usergroup Meeting
September 23-25, 2008
OVERVIEW
 Who are we?
 What were our challenges?
 What were our solutions?
Pyxis Usergroup Meeting
September 23-25, 2008
What were our solutions ?
• Proactive Audit
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Roberta Lowry , Nursing
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Mandate: (March 2005)
 Develop a business plan for a Proactive
Narcotic Diversion Monitoring Program
 Plan to include software, P&P, education
& staff
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Deficiencies of Existing System:
 Pyxis: insufficient data reporting (1 mo.)
 Pandora: reports don’t combine mirrored MS
 No dedicated EFT positions
 No data to project workload requirements
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Starting point:
Anomalous Use Report: Hospital–Wide All
Stations Report (for 9 mo)
Findings:
• 547 potential “highly likely” diversions
• 819 potential “highly suspect” diversions
Pyxis Usergroup Meeting
September 23-25, 2008
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Where do we start???????
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Narrowing the choices……..
 Select a drug likely to be used in many areas
 Select an area with a single MS
……..and the winner is
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Diazepam 10 mg tablets
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Next step……
• Pandora Anomalous Use Report for selected MS
nurse
patient
time frame
Findings…..
• Mean removals for all MS = 77
• Selected MS: Max = 660 (2nd = 431)
Next step….
• Audit 1 health record with diazepam+++ use
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Findings:
All diazepam accounted for on MAR, but
 Dose not always indicated (ROD order)
 Initials missing from MAR & Signature Record
 Initials & signature of nurse who removed from
MS nowhere in the health record
 Nurse who signed MAR had no MS activity
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Now what ???
1. Meet with Manager
 Mystery nurse identified
2. Select other nurses with same EFT, similar
rotations and run activity reports (Pyxis OPS)
3. Health record audits (Manager)
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Findings:
1. Nurse removes:
 approx = amt month/month
 amt similar to cohort for the specialty area
(5 mo; 325 vs 301 tab)
2. Doses removed from MS signed for on MAR but
>4 instances drug admin documented on MAR or
PN with no corresponding removal from MS
3. No personality or behaviour changes
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Conclusion
We could not find evidence of
diversion
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT
Some Measurable Costs of the Audit
Report generation & analysis
Report review (MOPC/DOPC)
Chart/MAR review
Meetings
20 hours!
Pyxis Usergroup Meeting
September 23-25, 2008
8h
2h
5h
5h
THE PROACTIVE AUDIT
Or,
> $800.00!!
Pyxis Usergroup Meeting
September 23-25, 2008
THE PROACTIVE AUDIT - Summary
Did our solution work?
Pro
 Some data on how long an audit would
take
Cons
x Lots of resources required
x Not always productive use of resources
x Software reporting tools not adequate
Pyxis Usergroup Meeting
September 23-25, 2008
What were our solutions ?
• Proactive Audit
• CII Safe
Pyxis Usergroup Meeting
September 23-25, 2008
CII SAFE
Jan Beales, Senior Pharmacist
Pyxis Usergroup Meeting
September 23-25, 2008
CII SAFE
Automated Checks & Balances







Purchasing/Receiving
Inventory
Compounding
Restocking/Returns
Expire, Waste, Recall
Outpatient Rx/Resale
Non- Pyxis Restocking Returns
Pyxis Usergroup Meeting
September 23-25, 2008
CII SAFE
Purchasing/Receiving Meds
 Suggested PO prints weekly
 Purchasing done by Purchasing Tech
 Med received and scanned into C2 Safe by
Narcotic Tech
 Invoice reconciled with Acquisition Record by
Manager/Pharmacist
Pyxis Usergroup Meeting
September 23-25, 2008
CII SAFE
Inventory/NarcVault
Access
 CII Safe controls both accessible
and remote stock
 All accessible inventory is counted
once a week by two narcotic
technicians
 All remote inventory is counted
once a month
 All CII Safe Events report prints
daily and is reviewed for unusual
activity
Pyxis Usergroup Meeting
September 23-25, 2008
CII SAFE
Compounding
 CII Safe automatically
reduces bulk inventory
and increases unit dose
quantity for compounded
item
 If item not returned to CII
Safe a variance is
created on the Pyxis vs.
CII Safe Report
Pyxis Usergroup Meeting
September 23-25, 2008
CII SAFE
Medstation Restocking/Returns
Restocking
 Communication link between MedStn & CII safe
 Meds removed from CII safe must be loaded into MedStn
or a variance is created
Returns
 Removals from a MedStn must be returned to the CII
Safe or a variance is created
Overall
 Open Discrepancy & Pyxis vs CII Safe reports are
printed daily.
 Pyxis vs CII Safe report picks up loads, returns, loads to
wrong machines, return bin variances, unload variances
 Variances resolved daily by narcotic tech
Pyxis Usergroup Meeting
September 23-25, 2008
CII SAFE
Expire, Waste, Recall
 Med’s returned first, then expired, wasted, or
recalled
 Meds pending destruction report reconciled
with return bin contents
 Requires witness to empty return bin
Pyxis Usergroup Meeting
September 23-25, 2008
CII SAFE
Fill a RX /Sell to Another Pharmacy
 The All CII Safe Events report shows “fill a
prescription & rx sales”. These are reconciled
with signature delivery sheets and RX or sales
report
 Only Pharmacists & Narc Techs have access to
Sell to Another Pharmacy
Pyxis Usergroup Meeting
September 23-25, 2008
CII SAFE
Non- Pyxis Restocking/Returns
 Narcotic Control Record (NCR) generated for non-Pyxis
areas
 Barcoded for tracking of outstanding forms
Restocking Locked Drawer
 Signature delivery sheets returned to pharmacy
Returns
 NCR scanned upon return to pharmacy
 Labels & Returns on NCR’s reconciled with signature
delivery sheets & return reports
 10% of NCR’s audited for complete information
Pyxis Usergroup Meeting
September 23-25, 2008
CII SAFE - Summary
Was it a solution?
Pros
 Automated areas increased tracking and
reconciliation of narcotic transactions to 100%
 Gained efficiencies in staffing
 Expanded services and track more medications (all
control drugs)
Cons
X Generates lots of paper
X Only 10% monitoring in non-pyxis areas
X Still too many non- pyxis high use narcotic areas
Pyxis Usergroup Meeting
September 23-25, 2008
What were our solutions ?
• Proactive Audit
• CII Safe
• Expansion of Pyxis
– Psychiatric Hospital
– Cart fill wards (ICU,
Peds) added Pyxis for
narcotics only
– Anesthesia use in OR
Pyxis Usergroup Meeting
September 23-25, 2008
PYXIS FOR ANESTHESIA
Working with the Physicians
Monique Yakiwchuk, Pharmacy
Pyxis Usergroup Meeting
September 23-25, 2008
DEVICE SET UP
 No OR Admitting feed
 Set up as Non-Rx, Dr’s
as patients
 Pharmacy sets user
templates
Pyxis Usergroup Meeting
September 23-25, 2008
CLINICAL DATA
 Add to clinical data
category “ENTER NCDUR #”
 Narcotic Control Drug
Utilization Record
(NCDUR) – manual record
for the shift.
 Pharmacy reconciles
removals, returns and
wastes associated to that
NCDUR Dr’s activity
compared to the Pyxis All
Station Events Report
Pyxis Usergroup Meeting
September 23-25, 2008
RETURN BIN
 A double sized drawer
reserved for an internal
return bin
 Accommodates a large
quantity of returns
 Unloaded daily &
reconciled with manual
NCDUR / All Station
Events Reports
Pyxis Usergroup Meeting
September 23-25, 2008
PENDING MEDS
 Single dose pockets –
no beginning count is
required
 12 pocket mini drawers
 Anaesthesia Med
Station set on
“OVERRIDE”
Pyxis Usergroup Meeting
September 23-25, 2008
USER SET UP
USER ACCESS
 Approval for access from
Head of Anaesthesia
 Pharmacy Create user ID –
ANES + licence number
 Create Users as Patients –
will enable Dr’s to remove
under their own name
Pyxis Usergroup Meeting
September 23-25, 2008
EDUCATION & TRAINING
 Pharmacy Education & Support
– key to success of TEAM culture
Highlights
 Removals
 Setting up Kits
 NCDUR’s
 Returns
 Waste
 Demanding Recounts
 Document Discrepancies
Pyxis Usergroup Meeting
September 23-25, 2008
INVENTORY MANAGEMENT
 Maintaining accurate
Inventory according to
usage reports
 Pharmacy manages all
Attention Notices
 Loads / Refills and
Unloads are accurate
Pyxis Usergroup Meeting
September 23-25, 2008
DISCREPANCY MANAGEMENT
Monitor / Reconcile Discrepancies for ALL End Users
Reports Currently Being Used by Pharmacy:
DAILY
 Manual NCDUR’s compared to Pyxis All Station
Events Report – done every morning to reconcile anything not
matching
 Pyxis vs. CII Safe Compare - reviewed daily; detects
pocket refills, unloads, loading errors and potential diversion
 All CII Safe Events – reviewed daily; provides an account for all
activities
Pyxis Usergroup Meeting
September 23-25, 2008
OUTSTANDING DISCREPANCIES
 Narc Tech to follow up with the
end user
 Pull patient MAR for review
/compare to NCDUR’s & OR
record
 Un-resolvable occurrence report
completed & documentation
given to Senior Pharmacist
 Follow-up with Head of
Anesthesia
Pyxis Usergroup Meeting
September 23-25, 2008
PYXIS ANESTHESIA - Summary
Was it a solution?
Pros
 Anesthesia took ownership of their narcotic usage (no more nursing
involvement)
 Anesthesia workflow has changed with 24 hour access
 Ability to track electronically, an area with high narcotic volumes

Significant decreases in outstanding discrepancies
 Anesthesia & Pharmacy work as team
Cons
X
Return of manual NCDUR still not 100%
Pyxis Usergroup Meeting
September 23-25, 2008
What were our solutions ?
• Proactive Audit
• CII Safe
• Expansion of Pyxis
– Psychiatric Hospital
– cart fill wards added Pyxis for narcotics only
– anesthesia use in OR
• Security: Centre- Wide Process
Pyxis Usergroup Meeting
September 23-25, 2008
SECURITY
• Centre- Wide Process
 Standard Employee Application Form for all computer access
 Pyxis User Database – maintained by Nursing & Pharmacy
 BIOid registration handled by Nurse Educators or Pharmacy
 Monthly HR Turnover Report used to process terminations &
transfers to non-Pyxis areas
 Annual purge of users inactive for > 1 yr
 Expiry dates for students are grad dates
Pyxis Usergroup Meeting
September 23-25, 2008
OVERVIEW
 Who are we?
 What were our challenges?
 What were our solutions?
 What are the current barriers?
Pyxis Usergroup Meeting
September 23-25, 2008
What are the current barriers?
o Still have non-pyxis areas ( 10%)
o Proactive Diversion Surveillance
– Staff resource
– Reporting Tools
– Formalized process
Pyxis Usergroup Meeting
September 23-25, 2008
OVERVIEW
 Who are we?
 What were our challenges?
 What were our solutions?
 What are the current barriers?
 What are our future plans?
Pyxis Usergroup Meeting
September 23-25, 2008
What are our future plans?
 Pandora SQL Software
 Narcotic Diversion Education & Support for
Managers
 Quarterly Diversion Reports for Managers to
review and monitor potential problems
 Formal Investigation Template
– Intervention
– Checklist
 Formal Intervention Team
Hospital Pharmacy 2007 Vol.42 No.3 pp244-248
Pyxis Usergroup Meeting
September 23-25, 2008
OVERVIEW
 Who are we?
 What were our challenges?
 What were our solutions?
 What are the current barriers?
 What are our future plans?
 What is our wish list?
Pyxis Usergroup Meeting
September 23-25, 2008
What is on our wish list?
 Extra staff resources
 Pyxis Reporting capabilities- more dynamic
Medstation, console, and CII Safe reports (eg
>1 month at Medstation, large capacity for
large data)
 Fix Anesthesia set-up – discrepancy causes
drawer failure
 Interface Pyxis with electronic staffing
program & medical records to reconcile
staffing, patients & removal times
Pyxis Usergroup Meeting
September 23-25, 2008
NARCOTIC DIVERSION
Questions?
Pyxis Usergroup Meeting
September 23-25, 2008
NARCOTIC DIVERSION
BREAK OUT SESSION
What has worked well in your
institution?
What are your barriers?
What is your wish list?
Pyxis Usergroup Meeting
September 23-25, 2008