(Management Case Study) Establishing a Drug Diversion Response Team (DDRT) Within Risk Management at a Multi-Center Teaching Institution

Purpose: The organization formed an interdisciplinary controlled substance (CS) diversion prevention program committee named the Controlled Substance Oversight Committee (CSOC) in 2019 to establish core structure and processes that would optimize the detection and minimize the occurrence of CS diversion.  The committee is co-chaired by the Chief Pharmacy Officer and the SVP of Nursing Affairs and Support Services. Cases of CS losses are presented to the committee monthly with lessons-learned and opportunities for process improvement identified.  One of these improvement opportunities identified in 2021 was to ensure maintenance of an accurate repository of all action items identified during the investigation.

Methods: The CSOC established a Drug Diversion Response Team (DDRT) to investigate known or suspected cases of CS losses. CS policies have been standardized and the organization implemented diversion management software to monitor user transaction activity. Initial DDRT investigation consists of an interview with a Risk Manager and a representative from Human Resources. The institution developed an algorithm for conducting the investigation. To support the investigation, a Guideline for Controlled Substance Investigation Upon Suspected Diversion/Loss document that lists each step in the investigation algorithm and the responsible party for completion was implemented. This document also identifies items for the Pharmacist in Charge to report to regulatory agencies, when necessary. The CSOC assigned a repository location for filing all supporting documentation and evidence of completion for all action items identified during the investigation.

A CS Program Manager was hired in May 2021 and resides in the Risk Management Department. The program manager coordinates the DDRT investigation and serves as the Risk Management representative for the team, ensuring that the standard processes are followed and that all supporting documentation is filed in the repository. Expectations for reporting cases to the DDRT for investigation were also standardized with education provided to the staff. Reporting of DDRT updates were placed on the standing agenda for the monthly CSOC meetings.

Results: At baseline, the DDRT investigated 5 cases of suspected CS loss in the second quarter of 2021.  60% (3/5) cases were deemed compliant with completion of action items identified by the DDRT by having evidence of item completion on file.  After the interventions, the DDRT investigated 24 cases of suspected CS loss in the third quarter of 2021, for which 96% (23/24) were deemed compliant with completion of action items identified by the DDRT with evidence of completion filed in the designated repository.  The improvement was sustained the following quarter with 100% compliance observed of 24 cases reviewed by the DDRT.

Conclusion: Having a formal structure for conducting investigations under a dedicated Controlled Substance Program Manager embedded in the Risk Management Department increased the effectiveness of the DDRT.  Having a clearly defined process for initiating a DDRT investigation increased the number of cases reviewed.  The implemented process improvements also led to sustained compliance with completion of action items identified by the DDRT investigation.