Fast-thinking pharmacist keeps patients safe
During a recent shift, Shanna Kaczynski sensed something was not quite right.
Kaczynski, who was a senior pharmacy technician at the time, was set to prepare an IV drip for a patient, but when she opened up two morphine vials, she immediately noted the medication vial tops were difficult to remove — a sign they may have been tampered with before they arrived at Michigan Medicine.
“Everyone in pharmacy has been trained to spot something like this and procedures are in place to handle it,” said Carol Purcell, manager of the Pharmacy Diversion Prevention Program.
Following the set protocol, Kaczynski handed off the vials to her colleague Blake Taylor, who in turn alerted Michigan Medicine Security and the Diversion Prevention Team.
Subsequent analysis validated Kaczynski’s suspicions: The caps had been lifted, rubber stopper punctured, the medication replaced with a clear solution and the vials glued shut.
Kaczynski’s response led the Diversion Prevention Team to identify two additional altered morphine vials in the post-anesthesia care unit at University Hospital.
While an investigation is still ongoing, indications indeed point to the fact that the medication had been altered prior to arriving at Michigan Medicine. The situation has been reported to both the FDA and DEA.
“I want to thank Shanna and the entire pharmacy staff for their diligence,” said Jeff Desmond, M.D., chief medical officer at Michigan Medicine. “Shanna recognized that something was awry with the vials. Her willingness to speak up allowed us to detect this risk and prevent harm from reaching our patients.”
Michigan Medicine’s pharmacies handle hundreds of vials every day and every step is meticulously monitored and recorded according to policy and procedure.
It was Shanna’s familiarity and expertise with each medication that she handles that helped her spot the potential patient harm event.
“Our technicians are trained to identify any alteration in medication packaging that may be a patient safety concern,” Purcell said. “Shanna realized that these specific medication caps did not easily spin, as expected. This is why it is so important to inspect the volume and packaging of every medication, to ensure nothing is altered.”
Safety comes first
So what exactly is diversion?
“Drug diversion involves taking prescription medications and using them for a purpose other than what they are intended for,” said Purcell. If diversion is suspected, faculty and staff are encouraged to contact Purcell’s Diversion Prevention Team immediately. The multidisciplinary team aims to prevent, detect and respond to drug diversion.
“Patient and staff safety is at the core of what we do,” Purcell said. “This means keeping our patients safe from potentially-impaired caregivers, ensuring our patients receive the medication they are prescribed, getting staff into treatment for substance use disorders or, in Shanna’s case, preventing tampered-with medications from reaching our patients.”
Michigan Medicine policy requires all staff members — regardless of role — to report concerns about integrity of medications to their manager or supervisor, hospital security or the Diversion Prevention Team.
Concerns also can be reported via the anonymous compliance hotline at 1-866-990-0111.
“Even the slightest bit of suspicion is enough to warrant reaching out,” Purcell said. “If we don’t know about a concern, we can’t keep our patients safe or help colleagues who may be struggling with a substance use disorder. That’s what we care about and that’s why we’re here.”