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Rx for a pharmacy's vulnerability.

EVERY HEALTH CAM FACILITY MUST have its pharmacy well stocked with narcotics, amphetamines, and barbiturates. Not only must pharmacies operate with large volumes of controlled substances, but they also must handle a significant amount of cash in locations that are often open tO the public 24 hours a day.

Ninety percent of all narcotics in the country are either in hospitals or in manufacturing plants, making hospitals the targets of illegal substance abusers.[1]

The vulnerability of pharmacies may not appear as obvious as in other types of facilities.

* A nurse may divert small amounts of Demerol for personal use.

* A clerk may forge a doctor's script to obtain Librium illegally.

* A doctor might pilfer several red devils secobarbital sodium) for a friend. Sometimes it's just aspirin or baby formula; other times large amounts of drugs may be stolen.

Some actual cases may make pharmacy vulnerability even more real. For example, at a Baltimore hospital's pharmacy a clerk diverted 72,600 tablets of Valium-worth $13,000. In Stockton, CA, 18 cases of Valium were stolen from a storage area in what appeared to be an inside job.[2]

Since the vulnerability of health care facility pharmacies is widely known and acknowledged, health care security directors and their administrators must focus their attention on the physical security of the pharmacy as a first step toward reducing exposure.[3]

A pharmacy is basically vulnerable to three types of crime-armed robbery, burglary, and theft and diversion.

Armed robbery. Armed robbery is the theft of property through the use of force or the threat of force against a person. The individual who perpetrates an armed robbery in a pharmacy is often an addict who is easily excited and desperate.

To reduce the probability of in - [1] Betty Holcomb and Robert R. Rusting, Theft In Hospitals and Nursing Homes Port Washington, NY: Rusting Publications, 1983), p. 126.

[2] Holcomb and Rusting, P. 117.

[3] Holcomb and Rusting, P. 126. jury to pharmacy personnel, health care security directors should develop security awareness training programs.

The following tips should be used in such a program:

* Keep doors leading to the pharmacy area locked at all times.

* Install a peephole in the door leading to the pharmacy.

* Don't place service counters within reach or sight of the door leading to the pharmacy.

* Erect a bullet-resistant protective barrier between the customer and pharmacy personnel.

* Make openings in service windows as small as possible.

* Install duress alarms at the customer window and in at least one other location within the pharmacy.

* Train pharmacy personnel how to operate duress alarms properly, and emphasize to the pharmacy staff their own vulnerability to serious injury during a robbery.

* Install closed-circuit television (CCTV) cameras that cover customer windows, entrances, and the pharmacy vault. Mirrors are another alternative.

* Ensure lighting is adequate, especially if CCTV is used.

* Implement an alarm response procedure for law enforcement authorities and security personnel.

* Implement procedures for pharmacy personnel to follow during and after a robbery or an attempted robbery.

Burglary. The second concern is burglary-an unauthorized intrusion without confrontation. Anytime a pharmacy is closed, the potential for burglary exists for the facility.

A crime study of 300 teaching hospitals revealed the following about pharmacy burglaries:

* Most burglaries occurred between Friday afternoon and Monday morning.

* Most of the pharmacies burglarized were located in the basement of the health care facility.

* Most pharmacies burglarized were closed and unstaffed.

* When investigations were conclusive, 10 to 20 percent of the burglaries were committed by current or former employees.

* Entry to the pharmacies was most often gained through a locked front door.[4]

The following procedures will also help reduce a pharmacy's vulnerability to burglaries:

* Keep the pharmacy well lit at all times-even when it is closed.

* Install external doors that have solid cores and metal frames.

* Be sure door hinges are located on the interior of the pharmacy doors.

* Use only key-operated, mortised or rim-mounted, pick-resistant double cylinder dead bolts.

* Be sure dead-bolt throws extend at least one inch into the frame and are constructed of steel.

* Install an intrusion detection system (IDS), which should include volumetric sensors, door contacts, and window foiling.

* Be sure all customer windows are resistant to entry.

* Be aware of the potential entries via walls, floors, and ceilings.

* Integrate all skylights, vents, and ducts exceeding 96 square inches into the IDS.

* Be certain the pharmacy vault either exceeds 750 pounds or is bolted or permanently affixed to the structure.

* Integrate the pharmacy vault into the IDS.

* Be sure the pharmacy vault is resistant to surreptitious entry for 30 minutes, forced entry for 10 minutes, lock manipulation for 20 hours,[5] and radiological techniques for 20 hours.

* Change vault combinations and rekey locks semiannually or when employees are terminated.

Theft and diversion. The Drug Enforcement Administration has documented that approximately 40 percent of all trafficking and abuse of controlled substances in the United States involves legitimately produced substances that have been diverted into illicit traffic.

Formerly, substantial diversion occurred in the manufacturing and distribution phases. Now, however, most diversion occurs through the illegal

[4] Bonnie S. Michelman and Susan C. Barton, Basic Training Manual and Study Guide for Hospital Security Officers, Unit 17, (Lombard, IL: International Association for Hospital Security, 1985), pp. 153-154.

[5] Hospital Pharmacy Assessment Instrument Communicorp Inc., 1988, p. 5. activities of physicians, nurses, and pharmacists.[6]

Simple theft of both controlled and uncontrolled substances occurs frequently. Theft of uncontrolled substances-over-the-counter items such as baby formula and aspirin-are common. Drugs may be simply slipped into an employee's pocket, or large quantities can be placed in the trash to be retrieved later.

Stolen and forged prescription forms used to obtain controlled substances are another problem security directors must address. Due to the availability of high-quality photocopiers, precautions should be taken against document falsification. Some protection is afforded through embossed or perforated, multicolor forms.

Drug diversion is yet another problem. Three methods of drug diversion are commonly used-manipulating documents, underadministering medication, and substituting substances.

[6] Ronald W. Buzzeo, "Cancer Pain Management: Use vs. Abuse of Narcotic Drugs," The Narc Officer Magazine, March 1989, p. 65.

Document manipulation occurs when a nurse logs out medication for a patient but never gives it to the patient. This usually happens on second and third shifts, where nurses are typically instructed not to wake a patient to administer medication. The nurse simply keeps the medication and hopes that if die patient complains, he or she is viewed as just another chronic complainer.[7]

[7] Holcomb and Rusting, p. 138.

This practice is common in pediatric wards, orthopedic wards, and oncology units. In pediatric wards children are not aware of what medication they are to receive, and patients in orthopedic wards and oncology units are frequently prescribed unlimited pain-killers on an as-needed basis.

Underadministering occurs when a patient is given less than the prescribed dose of medication. The balance is kept by medical personnel for their use.

Substance substitution, unfortunately, is possible since packaging is only tamper resistant, not tamper-proof. Tamper-resistant packaging defeats casual attempts, but determined individuals are limited only by their imagination. It is more difficult to divert drugs in a health care facility that uses a unit-dose system, but no packaging is fail-safe.

A substance can be substituted by either diluting or replacing it with water, saline, promethazine (phenergan), or hydroxyzine. The original substance is placed in a vial for sale outside the medical facility or retained for personal use.

One method of substance substitution is to cut the soft plastic back of a unit-dose tubex tray near the stopper with a razor blade or scalpel and insert a syringe to draw out the substance.[8] Only a close inspection will reveal a hairline incision.

Another substitution method is to remove the whole piece of plastic, remove the tubex, draw out the drug with

[8] Holcomb and Rusting, p. 139. a syringe, and insert another fluid. The tubex is then replaced, and the plastic is reattached with super glue.[9]

Such tampering can occur unobserved. Nurses usually go to a medication cart or cabinet, remove a tubex, put it in their pockets, and go to the restroom where they can do their tampering undetected.[10] requisitions; state a vial was contaminated and order a second vial; and fail to return drugs from patients who did not take them.

Theft and diversion of drugs are difficult to detect. The following suggestions will help reduce exposure to theft and detect theft and diversion activity:

* Keep storage areas and medication carts locked at all times.

* Conduct extensive background checks and periodic rechecks on personnel who hold sensitive positions with access to controlled substances. Highrisk individuals need to be kept out.

* Evaluate key control procedures.

* Restrict access to sensitive areas, and implement a coded ID system that will easily identify individuals in restricted areas.

* Review receiving and distribution procedures from the actual purchase order to floor distribution.

* Inform receiving personnel not to accept open cartons.

* Spot check medication entries on patients' charts. (One spot check revealed that medication had been issued while the patient was away in the Xray department.)

* Establish accountability with a documentation system of checks and balances to create a strict paper trail.

* Use undercover operatives and employee informants to develop internal theft intelligence. Good relations with nursing will provide support in this endeavor.

* Train employees, supervisors, and managers to recognize the signs of substance abuse.

Finally, health care security directors must take a preventive approach and not be afraid to use professional security consultants who specialize in health care facility security. An independent consultant can provide an objective opinion without prejudice or regard to internal pressures or politics. [12] The consultant can, in effect, let the chips fall where they may. [13] About the Author . . . John K. Law, CPP, is director of business development for Elite Investigations Ltd. in New York City. He is a member of ASIS and serves on the Standing Committee on Health Care Services. Law is also a member of the International Association for Hospital Security.

[11] Holcomb and Rusting, p. 119.

[12] James F. Broder, CPP, Risk Analysis And The Security Survey (Stoneham, MA: Butterworth Publishers, 1984), p. 130.

[13] Broder, p. 130.
COPYRIGHT 1990 American Society for Industrial Security
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Author:Law, John K.
Publication:Security Management
Date:Aug 1, 1990
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