What to Do When You Suspect Drug Diversion

By JoAnne Myhre, CPhT, BA, and Ann Byre, PharmD, of Allina Health.

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

Diversion in healthcare facilities is a serious issue that can jeopardize patient safety and create enormous legal liabilities to the organization. Because of these risks, healthcare facilities need to be proactive and have a plan in place that outlines how they will address an incident when it occurs.

In order to effectively address drug diversion, healthcare facilities must respond to incidents quickly and appropriately. Healthcare facilities need to consider developing a plan to facilitate the necessary steps when an incident occurs. This plan may include:

  • Checklists
  • Steps and decision trees
  • Key contact numbers
  • Forms
  • Relevant policies/procedures

Take a Team Approach

Monitoring for diversion cannot be a one-person effort. The best way to approach this topic is through a team method, with experienced team members offering support to the managers. A successful diversion team will be multidisciplinary and include human resources, a diversion specialist, supervisor, risk management, security, pharmacy and nursing.

Interviewing Suspected Diverters

When reasonable suspicion exists, it is important to ensure patient safety and consider the possibility that you need to remove the suspected healthcare worker from any contact with patients – meaning you need to plan for suspension of the staff member pending the conclusion of the investigation.

Don’t forget to ensure that drug cabinet access is suspended/discontinued as well. Make sure to notify relevant individuals, such as executive leaders, diversion specialist, human resources or security prior to confronting the suspected staff member.

When diversion is suspected, a detailed review of the suspected worker should be completed prior to an initial interview of the individual in question. This review should include reviewing medical records, drug cabinet records, dispensing discrepancies, personnel files, and any other pertinent data. If your facility or state allows for a drug screening test you could consider that as well.

The suspect interview is an extremely important step in determining what has occurred. Ensure that the interview takes place in a location that provides privacy and a quiet, distraction-free environment. Keep the group small during the process, selecting one person to take the lead. The goal is to allow the suspected diverter to explain their workflows, so others should refrain from input unless absolutely necessary.

What to Expect

Prepare for possible lengthy and often untruthful explanations for why it seems the diversion occurred, and investigate each scenario thoroughly. Make sure you have on hand all necessary documents, such as employee training records, time records, relevant discrepancy reports and information about peer performance. Some key issues to bring up might include:

  • Tampering and substitution of drugs
  • Patients that were denied pain relief
  • Medications that could be in the diverter’s locker or bag, or at their home
  • Duration of diversion, drugs and methods
  • Personal use or re-sale

Above all, plan for confession and/or impairment, and ensure the safety of all involved.

Drug Screening and Testing

When it comes to drug screening and other testing, consider the methods available and those most appropriate. Make sure the drug screen is observed and have a plan for after-hours testing. Bloodborne pathogen testing for conditions such as hepatitis B, hepatitis C and HIV may be an additional option as well.

Reporting Confirmed Diversion

After drug diversion has been confirmed, the diversion must be reported both internally and externally according to Federal and State laws. It’s vital to follow proper protocol, alerting a wide range of departments and individuals.


  • VP over the relevant department
  • Diversion Committee
  • Human Resources
  • Risk Management/General Counsel
  • Compliance
  • Security
  • Pharmacy
  • Finance

Externally, where applicable:

  • DEA
  • State Licensure Board and/or Professional Assistance
  • Department of Health
  • Law Enforcement
  • Pharmacy Board
  • Institutional Infection Prevention Department

Debriefing After an Incident

A crucial step in the aftermath of drug diversion in hospitals is for the facility to evaluate the effectiveness of its drug dispensing procedures. Re-evaluate the system, analyze data, identify and implement mitigation measures and keep up with best practices to prevent diversion in the future.


Guest Authors

JoAnne Myhre, CPhT, BA, is the Drug Diversion Program Manager for Pharmacy/Compliance Services at Allina Health, and Ann Byre, PharmD, is the Director of Pharmacy Services at Allina Health.  As health system level leaders, JoAnne and Ann collaborate and help lead both proactive and reactive components of the Allina Health Drug Diversion program.


Continuing the Diversion Discussion

As we further explore diversion management in our next post, we’ll focus on how you can develop a proactive diversion program at your healthcare facility.

View the previous post on diversion here.



2 thoughts on “What to Do When You Suspect Drug Diversion

  1. >Patients that were denied pain relief

    I think I might be a little confused here… how would denying patients pain medication signifying drug diversion? In this age of the growing opiate epidemic, I’m certain that denying patients pain medication is becoming an ever more common occurrence.


  2. Hey, If you or a love one is suffering with substance abuse, we are here to help…For a confidential conversation with one of our professionals, Call Now: (213) 322-1979


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