Identifying Vulnerabilities for Diversion of Controlled Substances to Inform The Safeguards Needed in Canadian Hospitals to Protect Patients and Healthcare Workers

Introduction: Diversion or theft of controlled substances (CS) is a recognized problem affecting healthcare systems globally. Diversion from hospitals can occur through falsifying orders, tampering with medications, and pilfering stock. The impacts of diversion are serious, causing severe harm to patients, healthcare workers, hospitals, and the public. Selecting effective interventions for safeguarding against diversion cannot occur without first having a thorough understanding of how the hospital system is susceptible to diversion. Aims: To establish a detailed understanding of how hospital medication-use processes are vulnerable to CS diversion, characterize the vulnerabilities, and develop a framework to conceptualize how system factors set the stage or shape processes for diversion to take place. Study Design/Approach: Guided by the System’s Engineering Initiative for Patient Safety (SEIPS) Human Factors model, I used a multimethod study design comprised of observations that informed a Healthcare Failure Mode and Effect Analysis (HFMEA) to identify critical failure modes (CFMs) in two Ontario hospitals in the inpatient pharmacy (Study 1), emergency department (ED) (Study 2), and intensive care unit (ICU) (Study 3). The prospective analysis was followed by a framework analysis to build a conceptual framework for diversion. Results: Study 1 demonstrated that CFMs provide detailed descriptions of vulnerabilities which exist in every medication-use process involving CS. Studies 2 and 3 built on these finding and showed that all CFMs stemmed in part from person-related factors (e.g., intentional actions to falsify documentation), but were always also precipitated by technology-, organization-, environment-, or task-related deficits in how healthcare systems are designed and organized. I developed a novel framework based on findings from Studies 1-3 to conceptualize the relationship between system factors and how they interact and coalesce to enable pilfering and/or forgery which leads to diversion-related harms. Conclusion: My thesis findings further our understanding of diversion as a systems issue, whereby vulnerabilities stem from failures not only by individual actions, but in the interaction between processes, technologies, environments, and organization factors. My framework can be used to inform broader efforts to develop guidelines and technological solutions for Canadian hospitals.

Department dc:contributor.department

Health Policy, Management and Evaluation

Year dc:date.issued

2022

Author dc:creator

• deVries, Maaike

Advisor dc:contributor.advisor

• Trbovich, Patricia

• Controlled Substances
• Diversion
• Health system safety
• Hospitals

Statement dc:rights

• Attribution 4.0 International

Licence dc:rights.uri

• http://creativecommons.org/licenses/by/4.0/

Handle dc:identifier.uri

http://hdl.handle.net/1807/123165

OAI identifier oai:identifier

oai:utoronto.scholaris.ca:1807/123165