Building a Network-Wide Drug Diversion Prevention Program at Hackensack Meridian Health

Deepika Nayyar, PharmD, MBA, BCPS, network pharmacy manager for quality, regulatory compliance, and accreditation at Hackensack Meridian Health (HMH), describes how HMH moved from hospital-specific diversion prevention efforts to a harmonized, network-wide program built on leadership commitment and multidisciplinary collaboration across pharmacy, nursing, security, legal, risk, and HR. She explained what a drug diversion prevention program aims to accomplish, the risk management strategy that drove its development at HMH, and the essential elements that any institution—regardless of size—needs to prevent, detect, and respond to diversion.

Pharmacy Times: Can you introduce yourself?

Deepika Nayyar, PharmD, MBA, BCPS: Of course. I'm Deepika Nayyar. I am the network pharmacy manager for quality regulatory compliance and accreditation at Hackensack Meridian Health (HMH). In this role, I develop and lead several network-wide initiatives to improve medication safety, regulatory compliance, pharmacy quality, and risk mitigation strategies at the system level. One of the things that I'm passionate about is the drug diversion prevention program, because it intersects between, you know, patient safety, medication safety, employee safety, and regulatory compliance.

Pharmacy Times: Can you describe the drug diversion prevention program and what it aims to accomplish?

Nayyar: Sure. A drug diversion prevention program is a proactive approach—I want to say a multidisciplinary proactive approach—to prevent, detect, investigate, and respond to diversions in a timely manner. So, prevent diversions from happening and detect and investigate as quickly as possible, ensuring that everything is set in place to do that, [and] ensuring we have policies and procedures in place and [they] are aligned. So, pharmacy policies and procedures aligned with HR policies, the team is on board with our response and our investigations, having a process for internal escalation and external reporting.

As you know, the diversion is a multifaceted effect. It not only affects the users, it affects the team members around that user, it affects the patients—whether it's inadequate treatment, billing issues, documentation—and then overall, legal risks and community reputation. If you find diversion at a hospital, then it reflects on the community. So, our goal as a network is to ensure that we are taking care of all of these things while ensuring regulatory compliance, taking care of our patients, taking care of our team members, and creating that culture of safety and just [overall] culture.

Pharmacy Times: What prompted the development of a formal drug diversion prevention program at HMH? Was there a specific catalyst, or was this part of a broader risk management strategy?

Nayyar: I'd say a broader risk management strategy. We had programs throughout our hospitals where…all my hospitals had a version of a drug diversion prevention program, but the process was not harmonized. So, we took a network approach where I connected with the C-suite leaders to get that leadership commitment and have a steering committee where we take all our diversion cases or issues to, are have that support to lead the program. And from there, having a multidisciplinary process where nursing, pharmacy, providers, security, legal, risk, HR, everybody is involved to create this program and creating a network-wide, consistent process, whether it's policies, whether it's auditing processes, whether it's investigation processes or reporting. Again, having everything clearly outlined, mostly creating that consistency [is key].

Pharmacy Times: What are the essential elements every drug diversion prevention program should include, regardless of institution size or setting?

Nayyar: I think one of the things that a successful program needs is leadership commitment and a multidisciplinary collaboration. That is, to me, the most important, followed by having policies, procedures, [and workflows] aligned, making sure the team knows what the workflows are—how to procure drugs, how to waste drugs, how to document—and having that process clearly established, ongoing education, ongoing surveillance, monitoring, auditing. And then, if it comes to a diversion, having processes where it makes it easier to detect diversion, [it is] then obviously easier to investigate and report.

And then for smaller institutions where they may not be able to get surveillance programs—because some large institutions may have [those]—my recommendation would be having that strong culture of accountability, governance, and the monitoring process, even if they're manual.