This product is an ASHP Learning Center https://elearning.ashp.org activity.
Accreditation
The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education with Commendation.
Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation
Target Audience
The Drug Diversion Certificate is intended to prepare clinical and administrative healthcare professionals to take an active role in activities related to drug diversion prevention, surveillance, and response in healthcare facilities.
Overview
The Drug Diversion Certificate curriculum addresses the following:
- The impact of drug diversion on patients, healthcare organizations, and healthcare workers who have diverted drugs and have a substance use disorder
- Drug Enforcement Administration (DEA) requirements for managing controlled substances
- Drug diversion prevention strategies that can be utilized in each stage of the medication use process, as well as in all physical locations and service areas
- Implementing a multi-modal system for drug diversion surveillance
- Responding to cases of suspected or known drug diversion
- Establishing a controlled substance diversion prevention program
Drug Diversion Certificate Requirement
Once a learner has completed the educational curriculum, they will have the opportunity to complete an online comprehensive exam. Once the learner completes the exam (minimum 80% passing rate; unlimited attempts permitted), they will earn the professional certificate.
Educational Activities
Introduction to Drug Diversion
ACPE # 0204-0000-25-726-H04-P&T
Application-based
2.25 contact hours
This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2.25 contact hours.
Learning Objectives:
- Define "drug diversion."
- Assess the impact of drug diversion on patients, healthcare organizations, and diverting healthcare workers.
- Summarize the issue of substance use disorder (SUD) in healthcare professionals and its consequences.
- Explain why SUD in healthcare professionals occurs and how to recognize it.
- Identify strategies to address drug diversion in a manner that supports the healthcare workforce and the individual professional while maintaining patient safety.
- Identify the risk of bloodborne pathogen transmission due to tampering and substitution practices of injectable medications as a method of drug diversion in healthcare facilities.
- Develop a plan for responding to an injectable drug diversion incident with the potential for infection transmission.
- Explain the role of law enforcement in cases of drug diversion in healthcare facilities and the value of having a law enforcement investigative partner.
Drug Enforcement Administration (DEA) Requirements for Managing Controlled Substances
ACPE # 0204-0000-25-727-H03-P&T
Application-based
1.5 contact hours
This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 1.5 contact hours.
Learning Objectives:
- Interpret the Drug Enforcement Administration (DEA) Code of Federal Regulations (CFR) as it relates to controlled substance processes.
- Compare the diversion standards from The Joint Commission, Det Norske Veritas, and the Centers for Medicare and Medicaid Services.
- Identify the order of a standard protocol for a Drug Enforcement Administration (DEA) inspection.
- Describe the purpose of the DEA Form 82 - Notice of Inspection of Controlled Premises (NOI).
- Identify the length of time that DEA registrants are required to maintain controlled substance records per the Code of Federal Regulations.
Drug Diversion Prevention Strategies by Stage of the Medication Use Process - Part 1
ACPE # 0204-0000-25-728-H04-P&T
Application-based
2 contact hours
This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2 contact hours.
Learning Objectives:
- Develop processes for procuring and receiving controlled substances that are compliant with regulatory requirements and decrease the risk of drug diversion.
- Describe best practices for controlled substance prescribing in inpatient and outpatient settings.
- Discuss risk mitigation strategies for patients receiving controlled substances on a long-term basis.
- Analyze a controlled substance prescription to determine if it was written by an authorized individual.
- Describe guardrails that may be used at the point of prescribing to minimize the risk of drug diversion.
- Give examples of surveillance strategies utilized to monitor controlled substance prescribing.
Drug Diversion Prevention Strategies by Stage of the Medication Use Process - Part 2
ACPE # 0204-0000-25-729-H04-P&T
Application-based
2 contact hours
This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2 contact hours.
Learning Objectives:
- Describe best practices for the preparation and dispensing of controlled substances (CS) that document accountability and decrease the potential for drug diversion.
- Explain strategies for access and utilization of automated dispensing cabinets (ADCs) that limit opportunities for drug diversion to occur and generate an auditable trail of CS movement throughout a healthcare facility.
- Describe situations when it may be necessary and appropriate for medications to be retrieved by a healthcare professional (HCP) other than the HCP who will administer the medication.
- Explain best practices for medication preparation and administration that minimize the potential for drug diversion.
- Identify patterns of as needed ("PRN") medication administration that are suspicious for drug diversion.
- Identify opportunities for diversion during controlled substance (CS) waste, return, and disposal/destruction processes.
- Describe best practices for CS waste, return, and disposal/destruction that decrease the risk of diversion.
Drug Diversion Prevention Strategies - Storage and Security
ACPE # 0204-0000-25-730-H04-P&T
Application-based
1.75 contact hours
This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 1.75 contact hours.
Learning Objectives:
- Describe strategies for the storage and security of controlled substances that decrease the risk of drug diversion.
- Identify locations in healthcare facilities where drug diversion may be more likely to occur and implement strategies to address diversion risks in these areas.
- Describe chain of custody (COC) requirements and the importance of an auditable trail during transfers of controlled substances (CS).
- Identify areas within healthcare facilities where there is a higher frequency of CS transfers and COC gaps within CS transfer workflows.
- Discuss key considerations when developing transportation workflows for CS to best maintain COC integrity, as well as the safety of personnel transporting CS.
- Discuss internal and external risk factors for drug diversion relevant to community pharmacy settings.
- Describe best practices for drug diversion prevention and surveillance in community pharmacy settings.
Drug Diversion Surveillance - Part 1
ACPE # 0204-0000-25-731-H04-P&T
Application-based
3.25 contact hours
This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 3.25 contact hours.
Learning Objectives:
- Identify physical signs that trigger suspicion for drug diversion.
- Describe behavioral signs that trigger suspicion for drug diversion.
- Analyze data to identify triggers that are suspicious for drug diversion.
- Describe high-risk metrics that may be strong indicators of drug diversion.
- Identify the risks of drug diversion involved with the procurement of controlled substances.
- Describe routine practices used to monitor for drug diversion during the procurement stage of the controlled substances medication use process.
- Describe best practices for controlled substance inventory activities.
- Explain the relationship between controlled substance inventories and proactive drug diversion surveillance.
- 7. Describe best practices for controlled substance inventory activities.
- Explain the relationship between controlled substance inventories and proactive drug diversion surveillance.
Drug Diversion Surveillance - Part 2
ACPE # 0204-0000-25-732-H04-P&T
Application-based
1.75 contact hours
This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 1.75 contact hours.
Learning Objectives:
- Describe the utility of dedicated drug diversion software.
- Explain multiple approaches to drug diversion software utilization in a health system.
- Discuss alternative monitoring tools when drug diversion software is not available.
- Describe types of surveillance camera systems and their specifications.
- Identify strategic placement of cameras for the purpose of drug diversion surveillance, as well as data storage requirements for camera surveillance footage.
- Describe best practices for drug assays and waste testing, as well as potential approaches for operationalizing drug waste testing.
- Compare technologies available for performing on-site drug assays.
Response to Suspected or Known Drug Diversion
ACPE # 0204-0000-25-733-H04-P&T
Application-based
4.5 contact hours
This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 4.5 contact hours.
Learning Objectives:
- Describe the investigative process for cases of suspected drug diversion.
- Give examples of internal and external reporting occurring as a result of diversion investigations.
- Evaluate the information included in a drug diversion scorecard to understand the background of an investigation.
- Identify deceptive behavior clusters during the interview process.
- Use effective interview questions and strategies to facilitate obtaining an admission.
- Explain processes and procedures that should occur following a drug diversion interview.
- Compare different types of employee drug testing and the advantages and disadvantages of each.
- Examine important elements of employee drug testing policies and procedures.
- Explain key considerations when investigating a suspected diversion that may require employee drug testing.
- Describe common drug testing procedures.
- Compare screening tests versus confirmatory tests and explain under which circumstances to use each.
- Explain common pitfalls that may occur when interpreting drug tests and how to avoid them.
- Explain responsibilities for reporting incidents of suspected or confirmed drug diversion.
- Describe methods for supporting healthcare workers involved in diversion and their team members after a drug diversion event occurs.
- Describe the resources available for healthcare professionals (HCP) with substance use disorder (SUD).
Establishing a Controlled Substance Diversion Prevention Program
ACPE # 0204-0000-25-734-H04-P&T
Application-based
2 contact hours
This nursing continuing professional development activity was approved by Maryland Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation to award 2 contact hours.
Learning Objectives:
- Describe the structure, scope, and responsibilities of a controlled substances diversion prevention program (CSDPP).
- Explain the role of the diversion response team (DRT).
- Recommend topics related to drug diversion prevention and response that should be addressed in healthcare organizations' policies and procedures.
- Explain proactive and reactive quality activities and their importance to an effective drug diversion program.
- 5.Give examples of key performance indicators (KPIs) that may be monitored in a drug diversion program.
- Describe a drug diversion gap analysis.
- Evaluate the results of a drug diversion gap analysis.
- Describe a plan for providing role-specific drug diversion education to staff in healthcare facilities.
Faculty Information
Diana Bottari, DO, ADM, ABOIM, FAAP
Medical Director
Controlled Substance Team
Advocate Health
Downers Grove, Illinois
John Burke, Commander (Ret.)
Executive Director
International Healthcare Facility Diversion Association
Bethel, Ohio
Bailey Eason, PharmD, MS, BCPS
Program Director – Drug Diversion
Northwestern Medicine Healthcare
Chicago, Illinois
Director of Marketing & Outreach
IHFDA
Kathy Federico
Vice President
Diversion Prevention and Community Engagement
Lifepoint Health
Brentwood, Tennessee
Katie Gauen Zuba, PharmD
Director of Compliance
Advocate Health
Chicago, Illinois
Karl Kappeler, MS, RPh, FASHP
Director
Children’s Hospital Services
Visante Consulting, LLC
Dublin, Ohio
Heidi McNeely, PhD, RN, PCNS-BC
Board Member
International Health Facility Diversion Association
Charles Town, West Virginia
Leah Mitchell, PharmD, MBA, CHC
Director of Compliance, Drug Diversion
Advocate Health
Charlotte, North Carolina
Michelle Nation, MHIA, BSN, RN, CIC
Infection Prevention Specialist
Tennessee Department of Health
CEDEP HAI/AR
Nashville, Tennessee
Danielle Neal, PharmD, MBA, BCPS, CHC, CPEL
Associate Vice President of Compliance - Pharmacy
Advocate Health
Charlotte, North Carolina
James O’Donnell, PhD, MS
Associate Professor of Pharmacology
Rosalind Franklin University of Medicine and Science
North Chicago, Illinois
Vice President
Pharmaconsultant, Inc.
Barrington, Illinois
Alexandre Raymond, PharmD, MS, CHC
Director of Compliance and Privacy
Ochsner Health
New Orleans, Louisiana
Samantha Roberts, PharmD, MBA, DPLA
Corporate Director of Pharmacy Regulatory and Compliance
Emory Healthcare
Atlanta, Georgia
Alex Rodriguez, MHIIM, CPhT
Lead Data Analyst
St. Jude Children’s Research Hospital
Memphis, Tennessee
Jennifer Splawski, PharmD, MS, BCPS
Director of Clinical Value
Bluesight
Chicago, Illinois
Kevin Vanover
Protective Services Investigator/Manager
TriHealth, Inc
Cincinnati, Ohio
Alissa Voils, PharmD, MSHA
Director of Medication Diversion Prevention
Mayo Clinic
Rochester, Minnesota
Kristin Waite-Labott, BSN, RN, CARN, CPRC
Founder and President
Wisconsin Peer Alliance for Nurses (WisPAN)
Hales Corners, Wisconsin
Callyn Wren, PharmD, BCIDP
Antimicrobial Stewardship Pharmacist
Healthcare-Associated Infections and Antimicrobial Resistance Program
Tennessee Department of Health
Nashville, Tennessee
Relevant Financial Relationship Disclosure
In accordance with our accreditor’s Standards of Integrity and Independence in Accredited Continuing Education, ASHP requires that all individuals in control of content disclose all financial relationships with ineligible companies. An individual has a relevant financial relationship if they have had a financial relationship with ineligible company in any dollar amount in the past 24 months and the educational content that the individual controls is related to the business lines or products of the ineligible company.
An ineligible company is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The presence or absence of relevant financial relationships will be disclosed to the activity audience.
- No one in control of the content of this activity has a relevant financial relationship (RFR) with an ineligible company.
As defined by the Standards of Integrity and Independence definition of ineligible company.
Methods and CE Requirements
Each activity consists of audio, video, and/or PDFs and evaluations. Learners must review all content and complete the evaluations to receive continuing pharmacy education credit for each activity.
Follow the prompts to claim, view, or print the statement of credit within 60 days after completing the activity.
Important Note – ACPE 60 Day Deadline:
Per ACPE requirements, CPE credit must be claimed within 60 days of being earned. To verify that you have completed the required steps and to ensure your credits have been reported to CPE Monitor, check your NABP eProfile account to validate that your credits were transferred successfully before the ACPE 60-day deadline. After the 60-day deadline, ASHP will no longer be able to award credit for this activity.
The ASHP Professional Certificates SM educational product line contains learning activities that are ACPE-accredited knowledge and application-based continuing education. This is not an ACPE Certificate Program. Upon successful completion of the activities, the learner will be able to download an ASHP Professional Certificate.
System Technical Requirements
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