Do you know what drug diversion looks like? How would you know if it was happening in your facility?

The U.S. Drug Enforcement Administration refers to drug diversion as employee pilferage. The term “pilferage,” according to Webster’s Dictionary, is “the act of stealing small amounts or small articles.” But don’t be fooled. An individual employee pilfering small amounts of medication can have significant implications for patients, providers and public trust.

Consider these points:

  • Patients may be denied pain management
  • The safety and welfare of patients, health professionals and other employees may be compromised if a provider is impaired
  • A hospital and/or physician group may be liable and could face criminal and/or civil consequences
  • Patients may be charged for medications that were not received; and public trust in the provider, hospital or health system may be diminished if diversion is not appropriately addressed

It is estimated that 10 percent of health care workers are dependent on some type of drug (about the same as the general population). Yet diversion is typically not easy to see. It can look like ordinary work, as in the regular ordering, receiving, dispensing, administering and wasting of medications. Health care workers most often divert for personal use and are extremely secretive.

Among this population, there is no standard type of diverter, though they are often people you’d least suspect, e.g. team leaders, new grads or long-term employees; sometimes diversion even occurs within a group of employees.

What to look for in a suspected diverter

Behavioral changes in a suspected diverter may include frequent tardiness or absences, frequent and unexplained disappearances, increased errors, sleepiness at work, inconsistent work quality, frequently volunteering for extra shifts, requests to work with certain patients, mood swings, irritability, a decline in grooming and/or pupillary changes.

When auditing for suspected diversion, look for these patterns among the person or persons in question:

  • Inconsistent or incorrect charting
  • Medication doses at the higher end of the dosing range
  • Being the only person who administers controlled substances to a patient, illustrating specific use with certain patients (elderly, non-English speaking or sleeping patients)
  • Late wasting (more than 30 minutes after the dose is given)
  • Documenting/scanning the controlled substance dose in a different location than non-controlled substances that were administered

Be aware of potential diversion areas

Some diversion is to be expected in any environment where controlled substances are procured, stored, dispensed or administered.

Some common risk points include:

  • Procurement: Purchase orders and packing slips are removed from records; unauthorized orders are placed.
  • Preparation and dispensing: Replacing controlled substance with similar-looking product during prepacking or in prepared syringes; manipulating inventory counts.
  • Prescribing: Prescription pads are diverted and forged; verbal orders are created but not verified; a prescriber self-prescribes.
  • Administration: Taking unused, patient-specific medications; documenting medication as given but not administered; for discharged or transferred patients, controlled substances are removed from automated dispensing machine.
  • Waste and removal: Waste is not adequately witnessed; controlled-substance waste is removed from unsecure waste container; waste in syringe is replaced with saline; and expired controlled substances are diverted from holding area. Important: Theft of waste is appealing because the medication is already expected to disappear.

Preventing diversion starts with a good plan. If you aren’t discovering diversion via your current program, it may be time to redouble your efforts, revising some procedures and reinforcing others. The 2017 American Society of Health-System Pharmacists (ASHP) Report: ASHP Guidelines on Preventing Diversion of Controlled Substances presents information about provider- and system-level controls and core administrative elements to consider for your diversion program.

Multidisciplinary teams are also a key to success and should include representation from the executive team, pharmacy, nursing, risk management, security, ethics and compliance and human resources. This team can provide organizational oversight and accountability, as well as support the investigation and reporting of suspected diversion.

These tips can help you determine who may be diverting controlled substances and some known areas within a practice or hospital setting where it may be taking place.

About the author. With more than 30 years of experience in the health care industry, Carolyn Liptak has provided directorial leadership for inpatient, outpatient, retail and specialty pharmacy operations and clinical strategy. Her areas of expertise include regulatory compliance, medication safety, controlled substance diversion surveillance, medication cost reduction and optimization, labor productivity management, and patient and employee satisfaction. Key achievements include the effective redesign of the pharmacy staffing matrix providing the infrastructure for the successful launch of decentralized clinical pharmacy services, antimicrobial stewardship and medication reconciliation programs.

Published: February 13, 2018