LAUSR

The patient safety field rightly focuses on identifying and addressing problems with systems of care. From the patient’s perspective, however, underlying systems issues might be less critical than another unspoken question: can I trust the people who are taking care of me? Last year, a popular podcast1 detailed the shocking story of Dallas neurosurgeon Christopher Duntsch, who was responsible for the death of two patients and severe injuries in dozens of other patients over two years. Although fellow surgeons had raised concerns about his surgical skill and professionalism almost immediately after he entered practice, multiple hospitals allowed him to continue operating until the Texas Medical Board revoked his license. Duntsch was ultimately prosecuted, convicted, and sentenced to life imprisonment, in what is believed to be the first case of a physician receiving criminal punishment for malpractice. Only a small proportion of clinicians repeatedly harm patients as Duntsch did, and the harm they cause accounts for only a small share of the preventable adverse events that patients experience. Understandably, cases of individual clinicians who directly harm patients tend to capture the public’s attention, as they vividly illustrate how vulnerable patients are when they entrust their health to a clinician. As a result, these cases have a significant effect on the patient’s trust in healthcare institutions. In this issue of the Journal of Hospital Medicine, Fan and colleagues2 describe the problem of controlled-substance diversion in hospitals and review the contributors and potential solutions to this issue. Their thorough and insightful review highlights a growing problem that is probably invisible to most hospitalists. Diversion of controlled substances can happen at any stage of the medication use process, from procurement to disposal and drugs can be diverted by healthcare workers, nonclinical staff, patients, and caregivers. Perhaps most concerning to hospitalists, diversion at the prescribing and administration stages can directly affect patient care. Strategies used to individualize pain control, such as using flexible dose ranges for opioids, can be manipulated to facilitate diversion at the expense of the patient’s suffering. The review presents a comprehensive summary of safeguards against diversion at each stage of the medication use process and appropriately emphasizes system-level solutions. These include analyzing electronic health record data to identify unusual patterns of controlled substance use and developing dedicated diversion investigation teams. These measures, if implemented, are likely to be effective at reducing the risk of diversion. However, given the complexity of medication use, eliminating this risk is unrealistic. Opioids are used in more than half of all nonsurgical hospital admissions;3 although this proportion may be decreasing due to efforts to curb opioid overprescribing, many hospitalized patients still require opioids or other controlled substances for symptom control. The opportunity to divert controlled substances will always be present. Eliminating the problem of drug diversion in hospitals will require addressing the individuals who divert controlled substances and strengthening the medication safety system. The term “impaired clinician” is used to describe clinicians who cannot provide competent care due to illness, mental health, or a substance-use disorder. In an influential 2006 commentary,Leape and Fromson made the case that physician performance impairment is often a symptom of underlying disorders, ranging from short-term, reversible issues (eg, an episode of burnout or depression) to long-term problems that can lead to permanent consequences (ie, physical illness or substance-use disorders).4 In this framework, a clinician who diverts controlled substances represents a particularly extreme example of the broader problem of physicians who are unable to perform their professional responsibilities. Leape and Fromson called for proactively identifying clinicians at risk of performance failure and intervening to remediate or discipline them before patients are harmed. To accomplish this, they envisioned a system with three key characteristics: • Fairness: All physicians should be subject to regular assessment, and the same standards should be applied to all physicians in the same discipline. • Objectivity: Performance assessment should be based on objective data. • Responsiveness: Physicians with performance issues should be identified and given feedback promptly, and provided with opportunities for remediation and assistance when underlying conditions are affecting their performance. Some progress has been made toward this goal, especially in identifying underlying factors that predispose to performance problems.5 There is also greater awareness of underlying factors that may predispose to more subtle performance deterioration. The recent focus on burnout and well-being among physicians is long overdue, and the recent Charter on Physician Well-Being6 articulates important principles for healthcare or*Corresponding Author: Sumant Ranji, MD; E-mail: [email protected]; Telephone: 415-206-2651; Twitter @sumantranji