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Drug diversion: policies and practices for prevention

The table below is a snapshot of the policies, tools and recommendations that are outlined and supported in the attached article written by Cardinal Health Professional Associates. The policies listed are recommended by Cardinal Health as optimal methods for preventing diversion, and many of them are also Joint Commission requirements. View and print full article [pdf file – 104 Kb] Issue Policy Pyxis® tools/recommendations Communication Organizational support Multidisciplinary approach Limiting access to medications All orders reviewed by pharmacist prior to administration (Joint Commission MM4.10) Profile mode Only authorized personnel have access (Joint Commission MM 2.20) Security setting Area table Define new user privileges User templates Limit temporary users Device settings Define process for terminated users User settings Fingerprint identification Pyxis® Bio-ID fingerprint identification Log out before timing out Console settings Managing returns and wastes Restrict return to stock Return bins Use standardized doses Waste on remove Require witness when wasting controlled substances Witness feature Managing overrides Capture reason for overrides Clinical data categories Require witness for overrides Witness feature Limit removal of multiple doses Too Close Warning Secure storage of controlled substances Store controlled substances in secure drawers (Joint Commission MM 2.20 (4M)) Pyxis CUBIE® pockets, carousel drawers and Pyxis® MiniDrawer with single med per tray Physically count controlled substances in a pocket Blind count Preventing diversion in the pharmacy Keep detailed records of controlled substance activity (Joint Commission 2.20 (4M), DEA requirements) Pyxis® CIISafe™ system Compare report Transaction report Bar coded sheets Store controlled substances in locked cabinet Pyxis® CIISafe™ unit Limit access to authorized personnel User templates Separate individuals to order and receive controlled substances Receive report Regularly inventory stock of controlled substances Narc vault access report Resolve discrepancies daily Discrepancy bulletin View open discrepancy report Correct original transaction report Resolve discrepancy report Store key in secure areas Secure locations for keys Secure and track expired medications Expired meds feature Label for expired meds

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