Audit finds issues with drug tracking at Richmond, B.C., health-care facilities

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An internal audit into drug management at Richmond, B.C., health-care facilities flagged several problems, including how anesthesiologists at Richmond Hospital track drug use and "wastage."

The audit, obtained through a Freedom of Information request, provides a window into the policies and equipment health-care facilities employ to stem illicit use and trade of sought-after pharmaceuticals, including morphine and oxycodone.

"[Vancouver Coastal Health] staff have a critical role in ensuring narcotics are not misused or diverted," the audit states.

"There is a risk that people within the health care system (patients or health care staff) abuse narcotics due to addictions, or divert narcotics for personal profit."

The audit, dated March 24, 2014, and marked "confidential," reviewed practices at Richmond Hospital and Minoru Residence, a residential-care facility, as part of a broader audit strategy at Vancouver Coastal Health, one of five regional health authorities in the province.

The audit noted several positive findings, including "adequate processes for narcotics issued from pharmacies to the units" and the use of password-activated machines to store narcotics at most acute-care units. Such machines "result in better physical safeguards and record-keeping processes," the audit said.

But it also noted two "high-risk" findings: gaps in drug documentation by anesthesiologists and mismatches between narcotic records and patient charts.

According to the audit, anesthesiologists at Richmond Hospital – which has eight operating rooms – sign out narcotics from an "Omnicell" machine and carry them in a lockbox or in their pocket throughout the day.

The anesthesiologists keep a paper copy of a record in which they enter the amounts of narcotics taken from the machine, the amounts administered to patients and the amounts returned to the machine.

Those logs are returned to a binder at the end of the day.

The audit found logs were sometimes not being completed as required, including 21 of 23 logs that were reviewed, or 91 per cent, that did not contain a witness sign-off for amounts wasted or amounts returned to the machine.

"Please note that there is a line on the daily narcotics records for a witness to sign off on amounts wasted," the audit states.

Without requiring a witness for wastage, "there is a risk of narcotics being diverted," the audit said.

The audit also looked at whether the amount of drugs noted on Omnicell or manual registries matched with the amounts noted on patient charts. Of 24 transactions reviewed, two did not match.

In one instance, 10 milligrams of morphine was taken from an Omnicell machine and three milligrams was documented as administered in the patient chart, leaving seven milligrams unaccounted for. The second instance was similar but involved a smaller amount – three milligrams – unaccounted for.

"If the register has an entry for narcotics administered and a similar entry is not made on the patient chart, there is a risk that narcotics may have been diverted," the audit said, adding that "it is acknowledged that the differences may also be due to wastage or other valid reasons."

Such discrepancies do not necessarily indicate major problems, said Dr. Michael Krausz, professor of psychiatry, epidemiology and public health at the University of British Columbia. Opioids are widely used for pain control, treating disease and other purposes and it is not uncommon to use part of a dose, he said.

"If you are not giving a full dose of a medication and then you destroy 50 per cent of the sample and then you are not writing that down properly, or documenting that, that may cause this gap," Dr. Krausz said. "It doesn't mean necessarily there is a misuse or abuse or a wrong dosage or anything like that."

But proper documentation is important and audits can help improve practices, he said.

The review included recommended management responses with target completion dates in 2014. Vancouver Coastal Health was not immediately able to provide an update on the status of those responses.