How to Spot Drug Diversion in Your Hospital

By Kimberly New, JD, BSN, RN, Diversion Consultant and Educator

This is the fifth in a series of posts about drug diversion.

Though drug diversion cannot be avoided entirely, paying attention to certain patterns and warning signs can aid in identifying a potential problem. The goal of healthcare facilities should be to take proper steps to prevent what they can, detect diversion quickly, and respond to any incident in an appropriate and timely manner.

Common Characteristics

When auditing for drug diversion in hospitals, it’s important to recognize who could be a potential diverter. In the last post on diversion, some of the common traits and behaviors of diverters were listed, such as:

  • Bright and persuasive—able to quickly provide explanations
  • Frequently disappears, such as to the bathroom or utility room, for prolonged periods of time
  • Volunteers for overtime or comes to work when not scheduled
  • Overly helpful; arrives at work before shift starts and stays late

This isn’t to say every healthcare provider who exhibits these characteristics should automatically fall under suspicion, but knowing behaviors commonly associated with diversion can be helpful in detecting it.

Commonly Diverted Drugs

Most often, a diverter chooses an opioid as a drug of choice, but may also divert other drugs as the diversion scheme progresses. In order to detect diversion, it’s important to know what types of medications are often diverted. Drugs of choice include:

Injectables:

  • Hydromorphone
  • Morphine
  • Fentanyl
  • Propofol

Pills and liquids:

  • Hydrocodone
  • Oxycodone
  • Benzodiazepines
  • Drugs to ease withdrawal and enhance impact of opioid (e.g. ondansetron, promethazine, diphenhydramine)
  • Non-scheduled (e.g. cyclobenzaprine, gabapentin)
  • Anesthesia gases

Top Ways Diverters Steal Medications

Here, in brief, are the top ten methods diverters use to steal medications from their healthcare facilities.

  1. Wasting complete doses – The diverter may claim the patient refused the medication.
  1. Removal of the drug under the sign-on of a colleague – Accomplished by stealing a password or by diverting when a colleague steps away from the cabinet without signing out.
  1. Dropping pills or breaking containers of injectables – The diverter may claim that undocumented doses are due to frequent clumsiness, or they may use this excuse for unwitnessed waste.
  1. Withdrawing medication without an order – Diverter may have an excessive number of override transactions and may allege forgetfulness in documenting verbal orders.
  1. Giving a patient a quantity less than ordered – The diverter may maximize diversion of waste by giving multiple partial doses instead of one complete dose.
  1. Cancelled transactions – Most often seen with drugs used to ease withdrawal, drugs that enhance the effect of an opioid, or those that may help mask the dilution of an opioid. When an injectable opioid is involved, this may be a sign of tampering and substitution.
  1. Duplicate doses – Used by less experienced diverters, who take one dose for the patient and in another transaction divert a dose for themselves.
  1. Removal of the drug for a discharged patient – Common in units with indistinct depart times, such as ambulatory surgery and the ED.
  1. Choosing a noncompliant witness – The diverter finds a co-worker who is complicit in signing off on unwitnessed waste.
  1. Withdrawing medications for patients who don’t need them – Though difficult to spot, this method may be used initially, but the diverter will usually escalate to methods more easily detected.

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Guest Author

Kimberly New, JD, BSN, RN

Kimberly NewKim New is a leading national expert on drug diversion. A former compliance specialist at the University of Tennessee Medical Center, New now serves as a consultant on controlled substance security and regulatory compliance to health care facilities across the country. She has served as the President of the Tennessee Chapter of the National Association of Drug Diversion Investigators (NADDI), and as a health care facility liaison to the NADDI Executive Board.

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Continuing the Diversion Discussion

In the next posts on drug diversion, we’ll go into more detail about each of these methods, and provide suggestions for detection and prevention.

View the previous post on diversion here.

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