Pharmacy Professionals > Opioid Strategy for Pharmacy > Improving the Safety and Security of Controlled Substances in Hospital High Risk Areas

Improving the Safety and Security of Controlled Substances in Hospital High Risk Areas

A new framework aimed at reducing the risk of controlled substances diversion within hospitals has been established through the collaborative efforts of several health system and pharmacy stakeholders. As the sponsor, and one of the members, of the Partnered Table to Improve the Safety and Security of Controlled Substances in Hospital High Risk Areas, the College is pleased to work with its partners to share the framework and contribute to system-wide responsibility aimed at reducing the harms associated with the misuse and abuse of controlled substances in our communities.

The Framework for Improving the Safety and Security of Controlled Substances in Hospital High Risk Areas contains 13 recommendations to enable healthcare system stakeholders to proactively identify and prevent the diversion of Controlled Substances in hospitals.

The recommendations recognize that the diversion of Controlled Substances can have a substantial impact on patients, staff and organizations. Identifying gaps in awareness, policies, procedures and capacity that increase avenues for diversion and acting to bridge these gaps is vital to preventing diversion in hospitals.

In addition to its development through a partnered table, the framework was also reviewed by additional healthcare system stakeholders to ensure it was applicable and relevant.

A Joint Effort

In late 2018, the College invited organizations that have made significant contributions to health care and medication management in Ontario to participate in a collaborative partnership to address the safety and security of Controlled Substances in hospital high risk areas. The group was established in early 2019 as an initiative of the College’s Opioid Strategy.

The Partnered Table to Improve the Safety and Security of Controlled Substances in Hospital High Risk Areas includes healthcare providers, hospital leadership, regulators and other subject matter experts. It was created to address some of the identified gaps in policies, procedures and capacity that increase avenues for diversion by putting in place multi-level system levers.

The organizations involved in developing the framework are: Accreditation Canada, Alexandra Hospital Ingersoll and Tillsonburg District Memorial Hospital, the Canadian Anesthesiologists Society, Canadian Society of Hospital Pharmacists (Ontario branch), Hamilton Health Sciences, Ontario Health (Quality), Institute for Safe Medication Practices Canada, Ministry of Health (Hospitals branch), Ontario Hospital Association, St. Joseph’s Hospital Hamilton, Thunder Bay Regional Health Sciences, University Health Network, William Osler Health System, and the College. A patient was also part of the group.

Recommendations from the Framework

The recommendations in the framework are intended to focus on system level solutions and act as guidance for health system leaders and organizations. The recommendations address identifying diversion, shared accountability and responsibility, culture of safety, collaboration, transitions of care and knowledge translation/sharing across the health system.

Read the recommendations in the framework.

Applying the Framework

The framework is meant to be a tool for hospitals to use as part of their overall work to enhance the management of controlled substances in their high risk areas and contribute to patient and staff well-being. Effective implementation of the recommendations will require collaboration across the hospital setting in order to identify any gaps and implement any necessary changes to policies, procedures, reporting, or training.

Pharmacists and pharmacy technicians working in hospitals are encouraged to become familiar with the recommendations, identify any gaps that might exist in their practice setting, and bring the framework to the attention of pharmacy and hospital leadership. It will be important to look for opportunities for collaboration with other healthcare professionals to identify where there is a role for pharmacy professionals to adjust, enhance or share practices around Controlled Substances. College hospital operations advisors will also share and discuss the framework with hospitals as part of their regular assessments.

External Resources

Pan-Canadian Diversion Risk Assessment Tool

FEATURED RESOURCES

FAQs

  • Hospitals are encouraged to review the framework’s recommendations to look for opportunities to enhance their own management of Controlled Substances in high risk areas. There should be collaboration across the hospital to identify any gaps and implement any necessary changes to policies, procedures, reporting, or training.

    Hospitals are encouraged to establish key performance indicators (KPIs) to evaluate their progress on improving the safety and security of Controlled Substances. Such indicators may include, but not be limited to, the number of Health Canada loss and theft reports, the number of confirmed diversions and the results of physical security and process audits on a regular basis to track the impact of their diversion prevention and mitigation strategies.

    Pharmacists and pharmacy technicians working in hospitals are encouraged to become familiar with the recommendations, identify any gaps that might exist in their practice setting, and bring the framework to the attention of pharmacy and hospital leadership. It will be important to look for opportunities for collaboration with other healthcare professionals to identify where there is a role for pharmacy professionals to adjust, enhance or share practices around Controlled Substances

  • The members of the Partnered Table to Improve the Safety and Security of Controlled Substances in Hospital High Risk Areas, including the College, will work collaboratively to identify future opportunities to measure the impact of the recommendations from the framework on diversion within hospitals and to hear feedback on implementation.

    College hospital operations advisors will be sharing and discussing the framework with hospital teams as part of their regular operational assessments in addition to activities and dialogue already underway during these visits regarding ensuring the security of Controlled Substances.

    The sponsorship of the framework by the College is part of our Opioid Strategy. Therefore, the College will also focus on encouraging implementation of the recommendations within hospitals by working collaboratively with various health system stakeholders.

  • Various health system stakeholders were involved in the information gathering, drafting and review of the framework.

    To ensure a wide regulatory lens was reflected in the framework, both the College of Physicians and Surgeons of Ontario and the College of Nurses of Ontario were given an opportunity to review the framework and provide feedback. They have also agreed to post the framework on their websites for use by their registrants.