How to Develop a Proactive Drug Diversion Program

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

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

The main priority of any drug diversion program is to ensure safety and protect patients from the harm that can be associated with diversion by healthcare personnel. While events that put patient safety at risk may not be completely eliminated, the potential harm can be reduced by taking a proactive, rather than reactive, approach to managing diversion.

It’s important to have leaders within the organization back the development of a diversion program. According to The Joint Commission (TJC), leadership engagement in patient safety initiatives is crucial, as 70 to 80 percent of all initiatives that require people to change their behaviors fail when there is no leadership directing the change.

Setting Up a Formal Program

A formal program for preventing, detecting and reporting diversion involves a collaboration of many departments such as human resources, nursing, pharmacy and risk management. A diversion oversight committee should be established. The committee will have responsibility for the development of procedures and policies, managing performance improvement measures, and providing overall direction for the program. Transparency and communication about diversion should be encouraged within the organization.

Role of a Diversion Specialist

Consider creating a Diversion Specialist position. The Specialist can focus intensively on diversion monitoring and liaise with groups within and outside of the institution. This individual should be an expert at using automated dispensing cabinet reports and analytics, and should maintain a database of diversion-related information and data to be tracked. In addition, the Diversion Specialist can help provide frontline education and support for all personnel.

Diversion Program Components

It is essential that the institutional response to diversion be made explicit in policy, so that decisions will not be influenced by emotion or preconceptions. A diversion program comprises pre-employment screening, staff education, regular auditing of drug transactions, a plan for response to suspected diversion, and ongoing physical security risk assessment.

Educating Employees

Educating all staff is a vital step in creating a successful drug diversion program. The goal is to develop a work environment where employees not only recognize the risks, but feel individual responsibility for reporting what they observe. Be sure to emphasize the importance of personal observation, as it in some cases may be the only clue to suspicious activity.

Employee education on diversion should be all-inclusive and occur at hire as well as at least once a year. Use actual cases of diversion in order to stress how to recognize diversion and the importance of reporting it. Also be sure to note the assistance options available to employees who may be abusing drugs. After all, it is better to prevent diversion in the first place rather than detect it afterward.

Reports and Analytics

An important part of a comprehensive diversion program is auditing of controlled drug transactions. Reports and analytics programs tied to the automated dispensing cabinets (ADCs) are helpful in uncovering diversion quickly and reducing the risk to patients and staff.

ADC Reports—These reports convey information about how nurses use the cabinets. It’s crucial to look at supplemental reports such as overrides, cancelled transactions and discrepancies, as they may help to identify habitual diverters and trends. For example, you can see how many times any one staff member selected to override a medication, which allows access to it without a specific pharmacy order for a patient.

Statistical Outlier Reports—Looking at statistical outlier reports, such as the Anomalous Usage report in Pandora analytics, can be an invaluable tool in swift diversion detection.  To help reduce false positives, be sure the settings of your program are properly calibrated. Managers may receive weekly analytics reports in order to monitor trends, but should limit auditing to monthly reports unless otherwise indicated.

For additional information about what to look for in these reports, see the previous posts:

Top 10 Tricks Diverters Use to Steal Medications: Part 1 and Part 2 

Additional Measures

In addition to analytics, other measures that can be implemented as part of a diversion program include:

  • Increased security for non-controlled substances with a high risk of abuse (e.g. cyclobenzoprine, propofol, anesthesia gases)
  • Daily pain rounds to determine if patients’ pain levels correlate with the amount of pain medications they are administered
  • Submitting all controlled medication “waste” in areas where surgery or other invasive procedures are done to pharmacy for reconciliation
  • Use of surveillance cameras and biometrics/badge access technology in high risk areas

Also, consider reviewing:

  • Verbal orders physicians claim they didn’t give (“rejected orders”) and rejected charges for controlled drugs
  • Patient complaints and survey responses relating to unrelieved pain
  • Incident reports relating to controlled medications
  • Trends for drugs used to ease withdrawal symptoms, such as promethazine, ondansetron and diphenhydramine.

Assess Your Diversion Program

It is crucial to regularly review your diversion program to ensure it is operating as effectively as possible and to make any necessary changes or improvements. A robust diversion program will help protect staff and patients from harm.


Guest Author

 Kimberly NewKimberly New, JD, BSN, RN

Kim 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.


View the previous post on diversion here

Diversion Management Webinars: To learn more about diversion, view our series of Diversion Management webinars hosted by Omnicell and presented by Kimberly New.


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