Medication Waste in the Operating Room

By Julie Vandenbark, MLS, BSN

Drug diversion is a known risk in health care but one that is difficult to quantify because it so often is unreported. It has been decades since the AMA first termed addiction as a disease in the 1980s¹ and yet there is still a widespread tendency to demonize or disdain the dependent individual leading to guilt, shame and secrecy. This contributes to the difficulty in documenting the scope of the problem. As a complex issue that presents multiple patient safety risks, one of the best means of preemptively addressing the problem is through careful attention to every process gap. For surgical settings, appropriate wasting of unused medication is an important step in preventing drug diversion.

Propofol is an excellent example of a widely-used medication that represents a risk, especially in surgical settings. 

Why focus on propofol?

Propofol, also known as Diprovan, is a short-acting, non-barbiturate medication primarily used by anesthesia providers for procedural sedation, monitored anesthesia care, or as an induction agent for general anesthesia sedation in operating rooms. It is also used for long-term sedation in intensive care units (ICUs), such as for critically ill patients who require a breathing tube connected to a ventilator. Although its status has been debated ever since the drug was identified as an important contributing agent in the 2009 death of pop star Michael Jackson, propofol is not scheduled under the Controlled Substances Act (CSA), making it more likely to be overlooked if security protocols are focused on scheduled drugs. 

According to the Institute for Safe Medication Practices, propofol is listed among the most commonly diverted medications.² It accounts for 41% of reported substance abuse cases among anesthesia providers.³ Ease of access by health care workers is a likely contributing factor. Single use vials may not be emptied and in the absence of a witness to validate the remaining volume to be wasted, this creates opportunity.

Accreditation standards offer a framework for appropriate drug handling

In addition to the consequences for a patient whose pain is not managed or who is at risk of a medication error, drug diversion can have serious, long-term, life-changing impacts for the diverter, ranging from license suspension or revocation to legal action, to potential overdose, or even death. Due to the extent of these risks to employees, patients, and health care organizations as a whole, medication security and disposal are critical areas of focus during an accreditation survey. ACHC Surveyors focus on medication safety, looking for evidence that drugs and biologicals are secured, administered and disposed of properly to prevent unauthorized access. For hospitals and ASCs, the relevant standards are under Pharmaceutical Services (Chapters 25 and 12, respectively). Drug diversion is focused on scheduled drugs in the hospital standards, but the intent extends to all medications and biologicals. The goal of accreditation with regard to this issue is that through policy, procedure, education, practice, data collection, evaluation, and corrective action, each organization adopts a continuous cycle of measurement and documentation to ensure the delivery of effective, high-quality care in a safe environment.  

Diversion Risk Reduction Strategies for Propofol 

Multiple diversion risk points exist in any organization and for a non-controlled drug like propofol, Surveyors see evidence of these on many surveys. Unlocked medication cabinets or carts, override features built into automatic dispensing cabinets, and unwasted, leftover vials in trashcans are just a few frequently observed examples. Each of these should be addressed through a drug diversion prevention policy that covers procurement, storage, distribution, preparation, dispensing, administration, wasting and documentation. 

The big picture ideas for risk reduction:

1. Promote a culture of patient safety, transparency and high-quality care for employees and patients through campaigns for safe medication goals that include oversight and accountability.
2. Engage pharmacy leadership, anesthesia and surgical service providers as collaborative partners for input on an effective disposal process. 
3. Review accreditation and other regulatory requirements.  

Action steps for your organization: 

1. Conduct a risk assessment.
   

   – Evaluate current medication waste policies and procedures against evidence-based practice guidelines and industry standards.
   – Identify high-risk areas in your organization (ORs, procedural areas, ICUs, etc.)
   – Identify current practice for medication movement from point of entry through waste, destruction or return to manufacturer.
   – Identify gaps in procedure that may create opportunities for unauthorized access (e.g., automatic dispensing cabinet override capability, packaging issues).

2. Consider designating nonscheduled medication, such as propofol, as a locally controlled item based on risk determination.
3. Use designated waste containers or carbon pouches that deactivate the drug on contact to ensure it cannot be retrieved once disposed.
4. Require preparation, dispensing and wasting be performed in teams of two. And rotate the pairs.  
5. Establish a diversion monitoring program to incorporate a check and balance system and implement routine surveillance.
6. Provide staff education upon initial orientation and at routine intervals about proper disposal policies and procedures as well as your drug diversion policy (including indicators of impairment and protections for whistleblowers).
7. Ensure prompt review of improper disposal or suspected diversion and implement corrective action plans and control measures as applicable.

An interdisciplinary approach will be necessary to address complex system issues. Tailored interventions may be required to reduce unauthorized or illicit propofol access. Assessment of risk, strong medication waste and security policies and procedures, and active surveillance can help prevent diversion activities and safeguard your employees and patients. 

– Julie Vandenbark, MLS, BSN, RN, is a Standards Interpretation Specialist for acute care and critical access hospitals. Before joining ACHC, she served as director of corporate integrity for a health care system in Ohio and has many years of accreditation program management and coordination experience. Some lucky organizations may meet Julie as an ACHC Surveyor, an aspect of her current role that keeps her keenly aware of on-the-ground challenges.

1 National Council of State Boards of Nursing. Retrieved April 20, 2023, from https://www.ncsbn.org/publicfiles/Understanding_the_Disease_of_Addiction.pdf 

2 Institute for Safe Medication Practices.  (2023, February 23).  Controlled Substance Drug Diversion by Healthcare Workers as a Threat to Patient Safety – Part I.  Retrieved March 28, 2023, from https://www.ismp.org/resources/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety-part-i 

3 Schneider, D., Ponto, J., Martin, E. (2017, December).  Propofol Disposal in the Anesthesia Setting:  Overcoming Barriers.  American Association of Nurse Anesthesiology.  Retrieved March 28, 2023 from https://www.aana.com/publications/aana-journal/journal-issue-detail/december-2017