Denis Fortier is Director of Pharmacy at Cheshire Medical Center in Keene. When he started in the field 30 years ago, that job involved loading carts with Dixie cups full of prescriptions.
Today, it involves managing $250,000 worth of technology called automatic dispensing machines.
"When people ask me how you describe an automatic dispensing machine, to me, it’s like an ATM for pills."
They look more like Zerox machines than ATMs. Cheshire has 15 of them throughout the hospital, each loaded with hundreds of different medicines. These are common fixtures at hospitals across the state.
Doctors enter in prescriptions through a computer. Then nurses and other medical staff use the machines, which are sometimes called cabinets, to access the drugs.
"It’s a touch screen. So I just put in my information..." [sound of touch screen beeping]
Fortier enters a password and requests some aspirin. A drawer with only aspirin slides open.
The cabinet’s software tracks every withdrawal like this. The process streamlines inventory and billing, and it helps ensure a patient receives the right medications.
But for pharmacists, the machine’s best feature is its ability to prevent drug theft. Around the country, so-called drug diversion incidents are on the rise. The DEA reports that in 2010, there were nearly 2,000 criminal investigations into suspected thefts nationwide.
Pain medications are the most sought after. That’s troubling for a state like New Hampshire, which ranks in the top 10 for abuse of painkillers.
Fortier says he’s hearing more and more about powerful drugs ending up in the wrong hands.
"My son-in-law is a police officer, and he always talks about Oxycontin, which is a big one on the street. And Vicodin, which are the two biggies from an oral standpoint. And narcotic injectables, things like Fentanyl, Demerol, Morphine."
Those injection pain killers are what pose the biggest threat to patient safety. Not including Exeter Hospital, there are three documented cases nationally since the mid-2000s in which drug diversion led to the transmission of Hepatitis C.
Joseph Perz is an epidemiologist with the CDC, which tracks these events.
"In 2009, a surgical technician in Colorado was identified as the source of an outbreak in which about two dozen patients were infected with Hepatitis C."
In that case, the employee, Kristen Parker, admitted to stealing syringes of the drug Fentanyl. She injected herself, and then refilled them with a saline solution. Parker knew she was Hepatitis C positive; she was sentenced to 30 years in Federal prison.
Investigators are still trying to determine if a similar method was used in the Exeter Hospital outbreak, which has used automated drug dispensers since 1998.
But Denis Fortier says there are ways that employees can try to work around the cabinet’s controls.
One example is if a doctor prescribes one milligram of a pain killer, but the drug only comes in two milligram packages.
"The system will know that at some point in time, someone has to come back and document the fact that one milligram wasn’t given. There’s a waste. And that requires two individuals to do the waste."
One employee is supposed to observe the other destroying the unused medicine. If the employees are working in tandem, or if one nurse is too busy to watch the other, there is an opening for misuse.
The machine’s software monitors these waste teams and generates a report. That way hospital administrators can look for patterns. Is it the same two employees, or the same narcotic, being wasted over and over again?
That’s one thing these cabinets are very good at…tracking the medicines while they are in the system, and providing documentation for law enforcement.
"Certainly, automation has helped, it certainly helps the investigation, and I think it makes it somewhat more difficult."
John Burke is president of the National Association of Drug Diversion Investigators and worked in the Cincinnati Police Department for 32 years. He says that no matter how modern a hospital’s machines are, there is always going to be that window of opportunity after the drug is removed from the cabinet.
"A person who knows what they are doing can still obtain the drugs."
Burke says one major problem is the lack of reporting when diversion is suspected. New Hampshire health care providers and pharmacies have to report missing medications to the DEA, but not necessarily to law enforcement. Hospitals may choose to fire the employees, or steer them toward a rehab facility. In the Colorado case, Kristen Parker had shuffled through numerous health care settings, getting fired for diversion but never arrested.
Denis Fortier says that hospitals will always be targets for people addicted to pain killers.
"If you are looking for something, where do you go find it. Well, if I’m looking for corn, I go to the corn field. If I’m looking for drugs, I go where the drugs are."