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University of Kansas Health System, Kansas City, KS

The University of Kansas Health System

Submitted by:
Jason Kim, Pharm.D.

Implementation of Drug Diversion Education in a Health System


Drug diversion in health systems is a growing problem. A estimated 10-15 percent of healthcare workers misuse alcohol or drugs at some point in their careers. Mitigating drug diversion within The University of Kansas Health System started with education for healthcare workers. Recent improved processes of controlled substance monitoring and dispensing opened the opportunity to implement a formal drug diversion education program. This education was implemented across the enterprise as foundational knowledge and awareness in drug diversion recognition, reporting, and prevention.

Key Elements of Success

An education plan and program rallied health system leadership and led to  formalized processes for retrospective and prospective analysis surrounding controlled substance dispensing, deliveries, administrations and documentation. The outcomes of these studies outreaches of the study helped change human resource policies, not only focused on mitigating drug diversion and impairment, but also gives the health system’s staff clear direction on how to access impairment assistance.

Role of the Pharmacy and Pharmacists

The pharmacy department’s access to and responsibility for distribution and maintenance of controlled substances reporting analytics allowed us to play a pivotal role in leading a drug diversion oversight committee and education sub-committee. Pharmacy helped drive and lead initiatives and address issues on a multidisciplinary front. Key pharmacist roles included facilitating education deliverables resulting from increased reported diversion safety events to the establishment of a formal governing body analyzing controlled substance discrepancies coupled with corresponding action plans.

Lessons Learned

The full support of the health system multidisciplinary leaders was critical to our success. The top-down approach ensured the successful execution of this education program to achieve widespread awareness for all healthcare workers. The biggest challenge we encountered was finding a way to to message the non-clinical healthcare workers in a manner that was appropriate while maintaining the integrity of the educational intent. Doing a pre-post survey based on the education was the agreed approach as it captured the simplest message and the quickest assessment of knowledge on areas of focus. The biggest champions included pharmacy and nursing leadership working side by side on common goals with one mission.

Budget & Resource Allocation

No budget or resource allocations were necessary. Existing staffing resources were used to establish the structured setup of a drug diversion oversight committee and diversion / impairment education sub-committee.

Future Goals

The next steps are to sustain the formal structure of the drug diversion oversight committee and continue to develop and add education programs surrounding drug diversion in a health system. The education program has created a baseline for controlled substance analytics and identifying issues and areas to improve upon. Other expansive areas include efforts with local nursing and pharmacy societies on addressing the opioid epidemic. This project has been presented throughout The University of Kansas Health System in 12 clinical and non-clinical forums, the ASHP Midyear Clinical Meeting, and future Health System Safety Symposiums.