New Joint Commission Quick Safety Issue Addresses Drug Diversion and Impaired Health Care Workers

PUBLISHED: Apr 17, 2019
Relevant to: All Healthcare Organizations

The Joint Commission (TJC) has released a new Quick Safety Issue #48 to address drug diversion and impaired health care workers. According to TJC, drug diversion is a patient safety concern for a multitude of reasons including, but not limited to:

  • Unsafe care because of impaired health care worker performance
  • Infectious disease exposure because of contaminated needles and drugs
  • Insufficient pain relief because of analgesic drugs being used by health care workers instead of being given to the patient

According to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and the American Nurses Association (ANA), approximately 10% of health care workers are abusing drugs. The availability of drugs in health care facilities makes detection especially challenging.

TJC’s Quick Safety Issue #48 lists multiple patterns and trends that might indicate diversion. Some of these include, but are not limited to:

  • Missing controlled substances
  • Unverified verbal orders for controlled substances
  • Missing or “lost” prescription pads
  • Unwitnessed medication waste

See the Quick Safety Issue for the complete list of drug diversion patterns and trends. Organizations must have processes in place to quickly detect diversion. Specific strategies suggested by TJC include:

  • Implementation of systems the prevent drug diversion and abuse
  • Encouraging staff to report suspicion behavior
  • Prompt reporting to enforcement agencies

Included with today’s notice are example polices that address several ways organizations can prevent/respond to drug diversion and impaired health care workers.

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