Development of a Scheduled Drug Diversion Surveillance System Based on an Analysis of Atypical Drug Transactions

Epstein, Richard H. MD; Gratch, David M. DO; Grunwald, Zvi MD

Section Editor(s): Dexter, Franklin

doi: 10.1213/01.ane.0000281797.00935.08
Economics, Education, and Policy: Research Report

BACKGROUND: Drug diversion in the operating room (OR) by anesthesia providers is a recognized problem with significant morbidity and mortality. Use of anesthesia drug dispensing systems in ORs, coupled with the presence of anesthesia or OR information management systems, may allow detection through database queries screening for atypical drug transactions. Although such transactions occur innocently during the course of normal clinical care, many are suspicious for diversion.

METHODS: We used a data mining approach to search for possible indicators of diversion by querying our information system databases. Queries were sought that identified our two known cases of drug diversion and their onset. A graphical approach was used to identify outliers, with diversion subsequently assessed through a manual audit of transactions.

RESULTS: Frequent transactions on patients after the end of their procedures, and on patients having procedures in locations different from that of the dispensing machine, identified our index cases. In retrospect, had we been running the surveillance system at the time, diversion would have been detected earlier than actually recognized.

CONCLUSIONS: Identification of the frequent occurrence of atypical drug transactions from automated drug dispensing systems using database queries is a potentially useful method to detect drug diversion in the OR by anesthesia providers.

IMPLICATIONS: We combined data from an anesthesia or operating room information management system and a pharmacy dispensing system to identify two anesthesia care providers known to have diverted drugs. The methodology, if in use at the time, would have identified their addiction earlier than was actually recognized. This approach may be a useful method to detect drug diversion in the operating room.

From the Department of Anesthesiology, Jefferson Medical College, Philadelphia, Pennsylvania.

Address correspondence and reprint requests to Richard H. Epstein, MD, Thomas Jefferson University Hospital, 111 S. 11th St. Suite 5480G, Philadelphia, PA 191067. Address e-mail to

© 2007 International Anesthesia Research Society