9/23/2020 - Pharmacy Refresh – Flow of Pharmaceuticals and Diversion Surveillance

Jodie Skayhan, Pharm.D., R.Ph. Director of Pharmacy
James Barna, Pharm.D., R.Ph. Pharmacy Operations Manager

Transcript

1. Pharmacy Refresh – Flow of Pharmaceuticals and Diversion Surveillance Presented 9.23.2020 by: Jodie Skayhan, Pharm.D., R.Ph. Director of Pharmacy James Barna, Pharm.D., R.Ph. Pharmacy Operations Manager
2. Topics for Today’s Presentation u Appropriate Medication Management – How do we ensure the appropriate flow of pharmaceuticals at RWJNB? u Security of medications and diversion surveillance
3. Why do we Audit? u To establish best practices and ensure audit readiness regarding medication management u The auditing activities were conditions of the CMS plan of correction established 12.2018 u Condition 489.1: “The facility failed to ensure that all pharmacy records have sufficient details to follow the flow of pharmaceuticals through the hospital and maintain control of medications.”
4. Flow of Pharmaceuticals – Establishing the Chain of Custody u Condition of CMS participation, the hospital must be able to speak to all phases of medication management: u Purchase -> Receipt -> Storage -> Dispensation -> Administration/Waste u Applies to both CDS and Non-CDS medications
5. Flow of Pharmaceuticals – Establishing the Chain of Custody (cont’d) u What can you do? u Critical to deduct at the Pyxis – the Anesthesia Record must match the Pyxis Activity to satisfy this requirement u Example: Patient X has propofol documented as administered on the Anesthesia Record. CMS asks to pull Pyxis activity for Patient X. No propfol documented as dispensed – where did this medication come from?
6. Current State u Both CDS and Non-CDS being audited: u 97% compliance for CDS – 2020 YTD u 40 – 70% compliance for Non-CDS – 2020 YTD u Opportunity with Non-Control Medications u Expectation: Any medication documented as administered on Anesthesia Record must be deducted from the Pyxis to ensure the chain of custody – From Pharmacy to Patient
7. Diversion Surveillance – Pyxis Auditing u Performed Nightly u Most common findings: u Medication pulled under “ANES, patient”, not subsequently transferred u Missing waste documentation – Duramorph u Inappropriate waste volume u Expectation: Anesthesia leadership notified of any irregularity, follow up as directed based on finding
8. Rx Auditor – Diversion Surveillance Software u Run weekly u Surveillance software that combs through all CDS transactions through Pyxis and assigns a risk of diversion based on how many units are pulled for any CDS. Compares the individual to their peers and looks for trends outside of the median u Expectation: Anesthesia Leadership to Investigate and speak to Anesthesiologist. Report findings to Pharmacy and Chair. Trending – does this happen frequently with this Individual?
9. Discrepancies at Pyxis with Controlled substances u Discrepancy – Pyxis count does not match physical count u Reported out DAILY Monday – Friday at Hospital Safety Huddle and via email u Hospital Policy – All CDS discrepancies must be investigated and resolved within 72 hours u When resolving a discrepancy, be as descript as possible in the resolution reason field
10. Discrepancies at Pyxis – Interpreting the Reporting The user logged in when the irregularity identified flags in BOLD as identifier: Must look to previous transactions to identify and explain what occurred
11. Discrepancies at Pyxis – Resolving a Discrepancy
12. Discrepancies at Pyxis – Resolving a Discrepancy
13. Discrepancies at Pyxis – Resolving a Discrepancy
14. Discrepancies at Pyxis – Resolving a Discrepancy
15. Discrepancies at Pyxis – Resolving a Discrepancy u What if you cannot explain the discrepancy? u Reach out to your leadership – separate pathway for CDS discrepancy resolution that cannot be immediately rectified u Expectation: All discrepancies must be fully investigated and resolved within 72 hours, consistent with our CDS policy
16. Questions? Thank you for your time this AM Reach out to Pharmacy Leadership with questions – we are here to assist