Fall 2019, Opioids

Framework for Improving the Safety and Security of Controlled Substances in Hospital High Risk Areas Soon To Be Released

Banner Fall 2019 - Partnered Framework
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A new framework aimed at reducing the risk of diversion within hospitals has been established through the collaborative efforts of several health system and pharmacy stakeholders. As the sponsor of the Partnered Table to Improve the Safety and Security of Controlled Substances in Hospital High Risk Areas, the College is pleased to work with its partners to share the framework and contribute to system-wide responsibility aimed at reducing the harms associated with the misuse and abuse of Controlled Substances in our communities.

The Framework for Improving the Safety and Security of Controlled Substances in Hospital High Risk Areas contains a number of recommendations to enable healthcare system stakeholders to proactively identify and prevent the diversion of Controlled Substances in hospitals.

The recommendations recognize that the diversion of Controlled Substances can have a substantial impact on patients, staff and organizations. Identifying gaps in awareness, policies, procedures and capacity that increase avenues for diversion and acting to bridge these gaps is vital to preventing diversion in hospitals.

The recommendations in the framework are intended to focus on system level solutions and act as guidance for health system leaders and organizations. The recommendations address identifying diversion, shared accountability and responsibility, a culture of safety, collaboration, transitions of care, and knowledge translation/sharing across the health system.

In addition to its development through a partnered table, the framework was also reviewed by other healthcare system stakeholders to ensure it is applicable and relevant.

The framework will be released in the coming weeks.


The Partnered Table to Improve the Safety and Security of Controlled Substances in Hospital High Risk Areas is a collaborative group of healthcare providers, hospital leadership, regulators and other subject matter experts established to take action to improve the safety and security of Controlled Substances in high risk areas of hospitals.

In late 2018, the College invited organizations that have made significant contributions to health care and medication management in Ontario to participate in a collaborative partnership to address the safety and security of Controlled Substances in hospital. The group was established in early 2019 as an initiative of the College’s Opioid Strategy.

The organizations involved in developing the framework are: the Ontario Hospital Association, Thunder Bay Regional Health Sciences, the Canadian Anesthesiologists Society, Accreditation Canada, Hamilton Health Sciences, the Ontario Ministry of Health, University Health Network, Health Quality Ontario, Canadian Society of Hospital Pharmacists, Alexandra Hospital Ingersoll and Tillsonburg District Memorial Hospital, William Osler Health System, Institute for Safe Medication Practices Canada, St. Joseph’s Hospital, Hamilton and the College. A patient was also part of the group.

As a partnered table, its role is to review and consider available evidence and identify areas for improvement in relation to the diversion of Controlled Substances in order to establish recommendations, methods to promote a culture of safety, and ways to measure and monitor the impact of the recommendations. Each partner organization has also have committed to taking action to enhance the security of Controlled Substances and minimize the risk of diversion.


The framework is meant to be a tool for hospitals to use as part of their overall work to enhance the management of Controlled Substances in their high risk areas and contribute to patient and staff well-being. Effective implementation of the recommendations will require collaboration across the hospital setting in order to identify any gaps and implement any necessary changes to policies, procedures, reporting, or training.

Hospitals can also consider establishing key performance indicators (KPIs) to evaluate their progress on improving the safety and security of Controlled Substances. Such indicators may include, but are not limited to, the number of Health Canada loss and theft reports, the number of confirmed diversions and the results of physical security and process audits on a regular basis to track the impact of their diversion prevention and mitigation strategies. The Partnered Table will also be exploring how to measure the framework’s recommendations and monitor impact on how hospitals are addressing the risks of diversion.

Once the framework is published, pharmacists and pharmacy technicians working in hospitals are encouraged to become familiar with the recommendations, identify any gaps that might exist in their practice setting, and bring the framework to the attention of pharmacy and hospital leadership. It will be important to look for opportunities for collaboration with other healthcare professionals to identify where there is a role for pharmacy professionals to adjust, enhance or share practices around Controlled Substances. College hospital operations advisors will also share and discuss the framework with hospitals as part of their regular assessments.

Look for the release of the framework in the coming weeks in e-Connect.

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