Decreasing Controlled Substance Variances in an Adult Emergency Department

Substance use disorder affects 10% to 15% of health care workers. The adult emergency department at a large medical center has a 60% higher controlled substance transaction rate than inpatient units, increasing the risk of diversion. Diversion involves unlawfully removing controlled substances, whereas variances result from incomplete documentation during transactions. Key contributing factors include inconsistent adherence to medication management policies, omission of barcode scanning before medication administration, and insufficient documentation of waste during controlled substance handling. The aim of this quality improvement project was to reduce variances by ensuring consistent barcode scanning and immediate documentation.

An evidence-based intervention that incorporated standardized workflows and visual guidance was implemented for 15 weeks in the fall of 2025 to reduce controlled substance variances. By focusing on these key behaviors, the project sought to achieve lasting improvements in variance rates and patient safety.

During the 15-week implementation period, 152 variances were observed. The weekly variance rates ranged from 5 to 19, with a median of 10. Of the variances, 50% (n = 76) involved failing to scan the medication into the electronic health record, 20.4% (n = 31) involved failing to document the disposal of unused controlled substances, 17.1% (n = 26) involved documentation errors, and 12.5% (n = 19) involved documenting a medication removal before administering it.

This project revealed that workflow standardization and visual aids alone were insufficient in reducing variances related to controlled substance medications. Ongoing reminders, support, continued staff education, regular compliance monitoring, and a commitment to medication safety protocols are essential for sustainability, especially as patient volumes change.