Centralized monitoring for diversion prevention decreases controlled substance variances

Abstract

Background

Controlled substance (CS) stewardship is essential for regulatory compliance, mitigating diversion, and supporting patient safety. The development of a comprehensive CS diversion prevention program (CSDPP) is resource intensive and may take years to mature.

Objective

We rapidly address CS variances through monitoring as an initial step toward comprehensive CSDPP development.

Practice description

Diversion management software (DMS) was used for 2 years across the twelve acute care facilities of the integrated delivery network before implementation of the centralized team. During this time, inconsistent practices in reconciling CS variances created a backlog of 28,000 unreconciled variances in 2023.

Practice innovation

We created a cost-efficient centralized multidisciplinary team as the first step of developing a CSDPP to rapidly and efficiently monitor CS variances and through that monitoring, strengthen regulatory compliance while promoting CS stewardship practices.

Evaluation methods

We compared early data from the DMS with later data to evaluate apparent loss variances and accountability of drug disposition. Computer-based training provided education completion metrics. Pharmacy leaders reported regulatory agency contacts for 2023 which was compared with recorded contacts in 2024.

Results

Centralized, daily review of CS variances resulted in 100% review of all variant CS transactions within 3 months of team creation. CS stewardship improved. After 1 year, apparent loss variances decreased by 41%, accountability for drug disposition improved from 62% to 93%, and regulatory reporting decreased 41%.

Conclusion

Improving the monitoring portion of a CSDPP realized significant benefits within 6 months which extended and improved over a year: a significant reduction in apparent loss variances, enhanced regulatory compliance, and improved regulatory reporting. This initial foundation of centralized monitoring captured critical incremental benefits while establishing a structure within which to grow and expand the CSDPP.