Monitoring controlled substance usage in the perioperative and OR areas

BD Institute for Medication Management Excellence

Monitoring controlled substance usage in the perioperative and OR areas: anesthesia reconciliation reporting at Cedars-Sinai Medical Center

PUBLISHED: Jan 7, 2019

Andrew Geller, MD, Anesthesiology, Cedars-Sinai Medical Center

Karen Youmbi, PharmD, Pharmacy, Cedars-Sinai Medical Center

Chris Urbanski, RPh, MS, FASHP, Medical Affairs, BD

The opioid crisis and its impact on patients and healthcare workers

The opioid crisis, caused by many factors, including overprescribing of controlled substances,1,2,3 extends into our healthcare system, as workers afflicted with substance abuse disease have access to narcotics (opium and its derivatives such as morphine, hydromorphone, and fentanyl) and thus an opportunity to divert these medications from their intended recipients (patients) for illicit use by the healthcare worker to feed a substance addiction. Patients are thus at risk in several ways: they may not receive the intended dose of medication and therefore be undertreated, they may be at risk for infection due to contamination of the medication by the diverter and overall care may be compromised if the clinician is impaired.

Vulnerability in the operating room setting

Several studies have demonstrated that 10-15% of healthcare professionals misuse prescription drugs, with addiction being 5 times higher in some physician groups such as anesthesiologists when compared to the general population.4 Controlled substances (CS) are often used in the Operating Room (OR) setting to provide sedation as well as pain management while patients undergo delicate, potentially life-saving, procedures. In those situations, anesthesiologists are focused on managing dynamic patient conditions sometimes to the detriment of accurate documentation and reconciliation of CS used. At the same time, these situations provide opportunities to divert CS for anesthesiologists and other healthcare professionals suffering from substance abuse disorders. Hence, it is critical to implement processes to ensure CS accountability, prevent their misuse and provide safe patient care.

Reconciliation of controlled substance doses is a very manual process

Pharmacy departments are challenged to monitor the medication usage (dispenses, administrations, returns and waste of excess medication for procedures) that occurs perioperatively and are required to assure regulatory and accreditation compliance for controlled substance tracking, charge and billing compliance and track and maintain adequate inventory levels5,6,7,8—all in the interest of medication safety. Reconciling controlled substance doses (accounting for the total quantity of a dose unit, including the amount administered, plus the amount wasted or returned to pharmacy) can be a very labor-intensive process, as dispensing and administration transactions normally occur through separate medication technologies or may be accomplished manually. To assure that doses dispensed are fully accounted for, a manual reconciliation process is often employed, one which visually compares data extracts from different systems or manual logs.5,9 Due to the length of time required for this manual comparison, it becomes difficult to review every transaction and detect diversion activity.

The challenges of limited automation and/or interoperability

Disparate documentation systems in the OR creates challenges for diversion detection. Therefore, both anesthesia information management systems (AIMS) and automated dispensing cabinets (ADCs) in the perioperative areas should be utilized, allowing for a complete electronic view of the dispense and administration information for dose tracking and reconciliation. In many cases, only one of the two systems are electronic, requiring a manual reconciliation process. Even where both systems are electronic, interfaces may not exist or be limited in terms of capability, as not all electronic health record (EHR) vendors support a combined, aligned view of information to the same extent.

The key to an efficient and effective monitoring system

In order to connect two disparate systems to make them Interoperable, use of common medication terminology and formulary build synchronization for dosing units of measure is required. Once this step is complete, medications must be mapped between the two systems’ formularies to assure unique medication items are properly aligned. Transactions between the two systems can then be linked, to develop reports and real-time views that facilitate dispense reconciliation. This creates an efficient and accurate record of the dispense that has the potential to easily and quickly highlight any discrepancies in the process for more expedient resolution. An excellent example of an organization implementing this solution is the work done by the anesthesia, pharmacy and IT departments at Cedars-Sinai Medical Center in Los Angeles, California.

Paving the way to interoperability

At Cedars-Sinai Medical Center, there are over 5,000 controlled substance administrations in the OR setting each month. Prior to the implementation of system interoperability between the EHR and the ADC, the Pharmacy department employed a full-time auditing technician whose sole task was to ensure controlled substance accountability by manual reconciliation of anesthesia dispenses against administrations. The technician would run a retrospective ADC report and perform individual chart audits to identify discrepancies. If discrepancies were identified, the technician would email the provider to further investigate the issue.

This time-consuming and inefficient process made it clear that a new process was needed, one which would 1) alert providers to any discrepancies in real-time, before they completed a case and 2) assist the pharmacy staff in reconciling all dispenses in an efficient manner.

Through multidisciplinary collaboration between the Anesthesia, Information Systems, and Pharmacy teams, the Anesthesia Reconciliation Report was developed. The report alerts anesthesia providers of controlled substance discrepancies via a best practice advisory that occurs when they attempt to close their anesthesia encounter. The advisory provides an opportunity to reconcile dispenses in real time rather than waiting for a notification from pharmacy staff. The report can also be run on demand, allowing pharmacy staff to follow-up on outstanding discrepancies not resolved by the provider.

Overall, the report has allowed the organization to reconcile all of its anesthesia dispenses in an automated fashion and reduce the number of discrepancies identified after an anesthesia encounter has been closed. The auditing technician has been able to re-focus time previously spent on manual reconciliation on other high-risk processes.

Saving time and improving medication safety

By connecting dispensing data to EHR administration data, reconciliation of narcotics in the anesthesia and OR areas can be greatly improved, allowing staff more time to focus on controlled substances accountability to prevent diversion. In doing so, the potential for diversion may be reduced along with the risk for patient harm, eventually resulting in better and safer patient care.

Learn more

Each month on the BD Institute for Medication Management Excellence blog, thought leaders explore topics of critical importance to medication management, and provide additional ways to learn.

Now that you've read this article, deepen your understanding of the opioid crisis in healthcare by reading about the challenges of detecting and preventing diversion in hospitals. Then read the first in our two-part series in which pharmacy and nursing thought leaders consider how to get ahead of the problem via early intervention.


  1. Hellmann J. What caused the opioid crisis? Published 2018.
  2. What is the U.S. Opioid Epidemic? Published 2018.
  3. Opioid Overdose Crisis. Published 2018.
  4. Unique Challenges for Professionals in Addiction Diagnosis and Treatment. Butler Center for Research. 2015.
  5. Epstein RH, Dexter F, Gratch DM, et al. Controlled Substance Reconciliation Accuracy Improvement Using Near-Real Time Drug Transaction Capture from Automated Dispensing Cabinets. Anesthesia and Analgesia. 2016 Jun; 122(6):1841-55.
  6. Practitioner’s Manual: Section IV. Published 2006.
  7. Henriques V. Medication Management. Published 2018.
  8. United States Department of Justice. Pharmacist's Manual: An Informational Outline of the Controlled Substances Act. Drug Enforcement Administration, Office of Diversion Control; 2010:19.
  9. New K, Overmire L. Utilize ADC Transaction Data to Detect Diversion. Pharmacy Purchasing & Products. 2017;14(10):10-17.