General Policies for Preventing Drug Diversion

This is the first in a series of posts based on diversion management webinars hosted by Omnicell and featuring drug diversion expert Kimberly New, JD, BSN, RN, and other speakers.

The Fourfold Risk of Drug Diversion

As drug diversion becomes a rising concern in the healthcare community, controlling this activity is becoming increasingly important. Diversion significantly increases the risk of patient harm as individuals are tended to by impaired caregivers, deprived of needed medications, and subjected to bloodborne pathogens due to tampered-with injections. However, the risks of drug diversion extend to more than just patients. Diversion endangers healthcare institutions, staff members, and the general public.

Drug diversion can bring severe civil and regulatory liabilities to healthcare institutions. In addition, the negative publicity and loss of credibility to staff creates additional challenges. For the staff members who divert drugs, loss of license and legal penalties await, as well as increased risk for drug overdoses. And finally, those operating under the influence of drugs increase the likelihood of accidents as they work, drive, and operate in the general public.

Knowing this, the question then becomes: What can be done to prevent and protect against drug diversion?

Policies to Protect and Detect

A number of policies can be implemented to protect against and detect drug diversion within the hospital and pharmacy. Successful strategies begin with thorough diversion training for staff members before giving access to drug cabinets and controlled medications. Employee education on diversion should occur at hire, and also annually. This training should include a clear explanation of policies and expectations, and delineate correct use, storage, and disposal of medication.

New employees should sign a written statement prior to having access to medications, agreeing to be available during any diversion investigation.

Following are some specific areas to consider including in a diversion program.

  • Quarterly risk rounds—Have a team make surprise inspections, verifying that staff are following correct protocol for medication handling. These rounds should occur at least quarterly. The goal is to identify opportunities to make processes more secure.
  • Weekly inventories—Conduct inventory of controlled medication on a weekly basis to uncover discrepancies. The staff involved in this process should rotate or differ from week to week. These inventory counts help narrow the window when investigating discrepancies that may have occurred.
  • Medication rounding—In most facilities, nurse managers round on their patients on a regular basis. One way to identify diversion is to ask patients or their family what medications were given in the prior 24 hours and inquire about their pain control. If medications are documented and the patient denies that they received them, an investigation would be in order.
  • PCA storage, administration, and documentation—Limit opportunities for diversion and tampering by tracking exactly who has access to each drug and when they are accessing it. Securely store PCAs (patient-controlled analgesia) pending use, and make sure access to them is traceable. Having PCAs on a counter in a locked med room or in a general bin can facilitate diversion and tampering. Ideally, PCAs should be stored in a single access bin in the drug cabinet. New recommends randomly selecting a set of patients who are on PCAs and auditing their records to see if you can track the infusion and whether the total adds up properly.
  • Discontinuation of access to drugs—Make sure a process is in place to immediately terminate medication access privileges for staff who are suspended for suspicion of diversion, shifted to another position not requiring drug access, or terminated from the facility.
  • Waste—Waste issues can be very indicative of diversions, so they should be looked at closely. Wastes should occur prior to or immediately after administration. When waste-related issues arise, address them with the practitioners involved. For more information about detecting waste-related diversion, see our posts on the Top 10 Tricks Diverters Use to Steal Medications.

Using Audits to Detect Drug Diversion

Auditing is a process that should be, according to New, a “shared responsibility between pharmacy and nursing leadership.” Automated dispensing cabinet (ADC) transaction reports combined with analytics that provide statistical outlier reports work together to give an accurate depiction of where the drugs are going. Because nurse managers are familiar with the case load, local policies, and staff tendencies, they are often the ones to make conclusions about audit results. However, the intimate knowledge they have of their staff—and a desire to trust them—can lead to investigator biases when it comes to justifying small abnormalities in audits.

Promoting Objectivity—Strength in Numbers

To get full buy-in from nursing, it’s important to approach surveillance and auditing as a patient safety initiative. Make sure to also discuss the potential harm that can come to a staff member who is diverting narcotics.

One suggestion for improving objectivity of diversion audits is to use a team system to evaluate potential diversion situations. The numbers of a team add strength and credibility when it comes to decisions about what is, and is not, drug diversion. In addition, making these decisions as a team lessens the chance of an individual being put in the uncomfortable position of accusing another staff member of something illegal. New also suggests using a specific checklist when conducting the audits—outlining what to look for with transaction dates, times, and removals.

Role of Diversion Specialist

Between educating, auditing, investigating, and responding to cases of diversion, New suggests that a diversion specialist is needed to properly manage a diversion program. Ideally a full-time position, this specialist is responsible for analytic reviews, educating and promoting good preventive practices, and keeping policies and procedures up to date.

Diversion specialists seek to prevent legal penalties and negative publicity by guarding against breaches in protocol, and they thoroughly investigate when suspicion of diversion arises. In addition, they partner with other leaders in multi-disciplinary groups including anesthesiologists, pharmacists, risk management specialists, compliance officers, and others to determine when diversion has taken place.

Bridging the Gap: Room for Growth

When asked during a webinar “How strong do you feel your current policies and procedures are for managing drug diversion?” participants answered as follows:

  • 39 percent felt their procedures were strong or excellent.
  • 34 percent felt that their policies were adequate.
  • 28 percent felt they needed additional help.

Healthcare facilities seeking to strengthen their diversion prevention, detection, and response need to take a multi-faceted approach that is tailored to its individual characteristics. Above all, they need to make accountability a priority—enabling medications to be tracked from the moment they enter the facility and onward.

The stakes are high—drug diversion management should be considered a protective business strategy for healthcare institutions that impacts its perceived integrity and patient security.

Want to Know More?

View our next post in this series on drug diversion.

Visit for free resources to help take control of drug diversion. The site provides access to upcoming and past webinars on managing drug diversion.

Learn about Omnicell solutions for detecting diversion here.

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