Effectively addressing drug diversion is a challenging proposition for every health system. With abundant medication inventories spread across numerous access points, health care organizations can face serious legal, financial, and reputational risks as well as regulatory fines resulting from internal diversion and inadequate controls.

In 2018 for example, a large health care system agreed to pay a $4.3 million settlement for allegations of drug diversion, the largest settlement of its kind. Drug Enforcement Agency (DEA) investigators uncovered systemwide recordkeeping and controlled substance-practices violations. The DEA began its investigation after two employees – a nurse and an anesthesiology resident – overdosed on opioids at a system facility. The nurse’s overdose was fatal.

According a study conducted by the Mayo Clinic and published by the Healthcare Information and Management Systems Society (HIMSS), up to 15 percent of health care professionals are addicted to drugs or alcohol, compared to 8 percent of the general population. That means the chances are high that drug diversion could be happening within your health system.

“There isn’t an institution that’s safe or free from being affected by drug diversion,” says Katrina Harper, PharmD, MBA, BCPS, DPLA, senior clinical manager, Center for Pharmacy Practice Excellence at Vizient. “If you haven’t caught diversion in your institution lately, it means you may not be looking hard enough.”

Take action to prevent drug diversion

While many health systems have some form of drug diversion program in place, major gaps can exist in an organization’s prevention and detection efforts. Health care organizations must also establish a culture of accountability and reporting to effectively detect and prevent drug diversion.

“Even though it involves drugs, diversion prevention and detection are not just pharmacy or nursing issues,” says Harper. “A successful program requires a multipronged, multidisciplinary approach and must be a leadership priority.”

An effective program includes systems and technology to deter drug diversion, a culture that supports prompt identification and investigation of possible diversion, intervention when it is occurring, and follow-up to deal with outcomes of confirmed diversion.

Take a multidisciplinary approach driven by leadership. A successful drug diversion prevention and management program requires a multidisciplinary approach. A diversion prevention committee should include representation from the executive team, nursing, pharmacy, physician leaders, human resources, quality and safety, security, accreditation, and risk management, among others.

The team provides oversight and accountability, and it supports the investigation and reporting of suspected diversion. “A drug diversion program should be treated like your other patient safety committees with monthly meetings and ad hoc emergency meetings when suspected diversion arises. It’s not just something that’s on paper; looking for and mitigating the risk of diversion is an active process,” adds Harper.

Establish standards, policies and procedures. Organizational policies should promote a culture of safety and outline the responsibility of every employee to report potential diversion activities. The policies and procedures should detail how to report suspected diversion, the process the health system will use to investigate reports, and the possible consequences for health care providers or staff members who divert medications. Standards for how medications are procured, stored, secured, prescribed, administered and discarded should also be established.

These policies and procedures must apply to all shifts, all providers and every staff member because “diverters can be your best employees. You need to follow the same process with each investigation to eliminate bias,” says Harper.

Foster ongoing education and training. An educated and vigilant staff is a powerful resource for health systems in the prevention and detection of drug diversion. As part of orientation and annual training, hospitals should educate providers and staff with data that shows the scope of the problem nationally, how to identify signs of possible diversion in their facility and among colleagues, how to keep medication secure, and how to respond if they suspect or witness diversion. Training should include real-world examples so that employees understand the seriousness of the issue and view diversion as a patient safety initiative.

Commit to continuous readiness and improvement. As technologies change and potential diverters discover new vulnerabilities in medication dispensing systems, hospitals must continually examine their diversion detection and prevention strategies. Diversion team members should make regular safety rounds, ensuring providers and staff are following the correct protocol for medication handling. The goal is to identify opportunities to make processes more secure.

Perform regular auditing and monitoring. Auditing and surveillance are important tools in preventing drug diversion. Data reports should be monitored daily to identify potential signs of diversion, such as discrepancies in automated dispensing cabinet transaction reports, irregular trends in prescribing and other noticeable activities related to medication inventory.

“The act of auditing and monitoring is one of the biggest challenges for organizations because it requires a significant time investment and people can get pulled away for patient care priorities,” says Harper. She adds that organizations with dedicated resources, such as a full-time drug diversion specialist and software programs, can more easily identify and respond to suspected diversion.

Take steps before it’s too late

The stakes are high. Drug diversion endangers patients, providers, staff, as well as a health system’s reputation and financial well-being. Health system leaders can take steps to mitigate the risk of drug diversion in their facilities, and should work to do so proactively, before a problem occurs.

To learn about your organization’s risk for diversion, review the American Society of Health-System Pharmacists’ Controlled Substances Diversion Prevention Program Self-Assessment Guide. From there, don’t attempt to tackle every problem at once. Focus on your biggest gap first.

Don’t have the resources to develop and implement a comprehensive drug diversion prevention and management program? Contact Joyce Thomas, PharmD, associate principal, pharmacy advisory solutions, to find out how Vizient can help.

1 National Center for Health Statistics, Data Brief No. 293, December 2017
2 The National Survey on Drug Use and Health: 2017

Published: April 23, 2019