Fast Company

How Technology Thwarts the Real-Life Nurse Jackie

Nurse Jackie

Randy Lipps, CEO of Omnicell, knew his medical surveillance technology was working when a certain hospital group (kept anonymous because of medical privacy concerns) reported a sharp spike in actions taken against staff for swiping drugs.

Nearly 7 million Americans are abusing prescription drugs according to the DEA, more than the number abusing cocaine, heroin, hallucinogens, Ecstasy, and inhalants, combined -- an 80% increase over 2000. Some of that is average folks and their kids taking needed painkillers. But a significant portion involves those with mainline access to prescription pills and vials -- health-care professionals.

Whether they're taking pills for their own use or to sell, so-called "diversion" is a growing problem. "Most hospital staff are doing the right thing but the access is there," Lipps says.

To thwart diversion (and help hospitals with compliance regulations) several companies including Omnicell and Pyxis began manufacturing automated dispensers fully loaded with layers of security such as individual ID numbers, measured doses, and bar codes. Then diverters unwittingly helped them find the flaws. "Health-care workers found legit ways to subvert the system to get a second dose," Lipps explains. So team Omnicell set to work on developing software to crunch the data that was being generated at the automated dispensing sites. The results, recently unveiled, were an eye-popping lesson in behavior patterns.

"Every single keystroke is looked at," Lipps says, from the way the staff accesses information to what they take out. The new data presents patterns, which Omnicell links to diversion. For example, Lipps says, if a patient is on a drug to be administered every four hours, a diverter will be making a withdrawal from the dispenser at three hours and 59 seconds. "But that’s just one way," he says, explaining that the software allows them to look at an array of factors.

Forty-one hospitals are using or already contracted to use Omnicell’s medication surveillance, at a cost of $1,000 per month. Lipps says this sophisticated approach of daily reporting directly to a pharmacy supervisor has led to the discovery of even more diversion cases, like the aforementioned hospital with its long list of staff actions.

One study showed that drug diversion could be as high as 18% among nurses, an issue recently made popular on the Showtime series Nurse Jackie, starring Edie Falco as a high-functioning nurse addict who delivers witheringly smart repartees to her doctor colleagues as enthusiastically as she crushes Percosets into her coffee. Though Falco’s Nurse Jackie is too risky to be realistic, studies also indicate that nurses are more likely to be dealing with an occupational hazard: chronic back pain from spending hours on their feet as well as lifting and helping increasingly heavier patients and therefore more likely to use.

But nurses aren’t the only culprits. "Anesthesiologists weren’t suspected for a long time, because they are doctors," Lipps says, noting that Percoset tabs are administered in the OR before starting the IV dose, and he says, "You shouldn’t put past them saving half a vial to inject later on."

George Shea, director of pharmacy of Sequoia hospital, can remember when the only thing standing between the meds and the user was a locked cabinet and a ledger. In the course of his 32 year career, Shea’s even witnessed an anesthesiologist overdose on a patient’s meds while on duty. "It was an extreme case," admits Shea, who’s grateful that technology has stepped in and replaced the pencil, paper, and look-the-other way culture of the recent past.

"With the software detection, it is a lot easier to keep track of who does what. It is a major deterrent because they know someone can find out what they have done," Shea says, adding that even taking one pill at a time is enough to cause concern. "It is not observable but it can impair judgment throughout the day." Even routine tasks involve judgment, he says, and that can decrease a health-care worker’s ability to function.

Jane Hirsch, RN, MS, a clinical professor and director at the UCSF School of Nursing, says automated surveillance has an unintended benefit because of its anonymity. "Staff tend to avoid those situations, it is awkward and uncomfortable to confront a colleague" -- even though they know it is their responsibility to report diversion to a supervisor immediately, Hirsch says.

Now in his 40th year as a pharmacist, Ray Vrabel has held positions at the Mayo Clinic, Scripps, and UCLA and was even part of a DEA sting operation to catch a health-care worker who was stealing ephedrine to make meth. He says when it comes to controlled substance issues, you don’t hesitate to deal with the person, however, firing them immediately is not the goal. "We are not trying to punish people just keep them honest," says Vrabel, but he and Shea agree that even in an age of automated dispensing and surveillance technology, drug diversion is still happening to the tune of between 1% and 9% of staff per facility. Shea points out that in a typical medium-sized community hospital with 1,000 employees, 1% is 10 workers. "That is very real," says Shea noting that goes beyond nurses to include physicians and any other workers dispensing controlled substances.

It’s not a large amount of theft, but it's showing up more and more with systems like the one from Omnicell. "We live in a drug seeking world," Vrabel says. "We’ll never stop watching."

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