42 to Near Zero: A QI Approach to Anesthesia Drug Discrepancies42 to Near Zero: A QI Approach to Anesthesia Drug Discrepancies
Drug Diversion Insights with Terri Vidals
Terri Vidals talks with Dr Jenny Dolan about a multi‑year quality improvement project that dramatically reduced anaesthesia drug discrepancies using data, culture change and targeted interventions. The discussion focuses on documentation, diversion risk, visual analytics and the importance of strong partnerships between pharmacy and anaesthesia.
33:38•8 Apr 2026
From 42 Errors to Near Zero: How One OR Transformed Controlled-Drug Accountability
Episode Overview
- Tight, accurate documentation is essential for both patient safety and any realistic assessment of diversion risk.
- Structured QI methods, such as a theory of change and a logic model, can turn a chronic discrepancy problem into measurable improvement.
- High‑impact interventions included disabling drug transfers between patients, linking physician pay to narcotic discrepancies, and using clear visual dashboards.
- Institutional backing, especially from pharmacy, security and HR, is crucial when staff resist data transparency or claim harassment.
- Effective diversion monitoring in the OR must respect clinical workflow so that tighter controls do not unintentionally compromise patient care.
“How can you confirm that you're providing excellent care when you don't aim to also have excellent documentation?”
How do different strategies aid in addiction prevention inside hospitals? This episode of Drug Diversion Insights offers a rare, candid look at how one anaesthesia team slashed controlled-drug discrepancies from around 40 a month to just three – and what that means for both safety and potential diversion. Host Terri Vidals talks with Dr Jenny Dolan, Division Chief of Paediatric Anaesthesia and Director of Trauma Anaesthesia at Johns Hopkins All Children’s Hospital.
Sparked by pharmacy concerns and regulatory pressure, Dr Dolan led a multi‑year quality improvement project that tackled issues such as undocumented waste, medications removed without charting, and sloppy habits that can hide early warning signs of diversion. You’ll hear how she used a theory of change framework and a logic model to structure seven interventions over almost three years.
These ranged from simple reminders on anaesthesia machines, to disabling the popular but risky “transfer to another patient” function in the dispensing cabinet, to tying physician compensation to narcotic discrepancies. A visual analytics dashboard then made everyone’s data transparent – quietly backed up with some humour, team photos and medical jokes on the same wall to keep people actually looking at the numbers.
She explains how the AI tool “protonus” flags outliers, how new staff often experience a “culture shock” around strict controlled‑substance expectations, and why documentation quality is inseparable from claims of excellent patient care: “How can you confirm that you're providing excellent care when you don't aim to also [have] excellent documentation?” For anyone working in diversion monitoring, anaesthesia, or pharmacy who’s tired of hearing “it’s just documentation”, this conversation offers practical strategies, cautionary tales and hope that meaningful change is possible.
Dr Dolan shares how cultural resistance, accusations of harassment, and fear of blame were countered with institutional backing, HR support and clear, accurate data. What small step towards tighter accountability could your team start with this month?
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