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.

The 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.

Next Steps

The College will continue working with the Partnered Table to Improve the Safety and Security of Controlled Substances in Hospital High Risk Areas members to identify opportunities to measure and evaluate the impact of the recommendations from the framework. The recommendations are meant to be evolving and will be regularly reviewed for quality improvement.