Drug Diversion: The Impact on Infection Control

This is the fourth in a series of articles based on diversion management webinars hosted by Omnicell and featuring drug diversion expert Kimberly New, JD, BSN, RN, and other speakers. This post is based on information presented by guest speaker Dr. Joseph Perz of the Centers for Disease Control and Prevention.

The Risk of Infection

Whenever diversion occurs, there are multiple ways patients may suffer harm. Drug diversion can prevent patients from receiving prescribed medications—resulting in failure to obtain adequate pain management—and exposes them to substandard care when the provider delivering that care is impaired themselves.

In addition, through the two main mechanisms for diversion—scavenging and tampering— patients and healthcare workers are put at risk for exposure to life-threatening bloodborne infections.

  • Scavenging exposes the employee to infection when leftover medications in used syringes, vials, and needles are injected, and has led to a number of healthcare workers becoming infected with diseases like hepatitis C.
  • Tampering exposes the patient to infections when healthcare workers inject the medication into themselves and then inject a substitute saline solution into the patient using the same needle or syringe. Tampering can cause both bacterial contaminants and viruses to be transmitted to patients.

In one case of tampering, an EMS technician was taking vials of fentanyl, removing the drug for his own use, replacing the contents with saline, and gluing the caps back on. This led to a number of questions—specifically in regards to how that drug was withdrawn, and whether the technician had used a contaminated syringe or needle to replace and administer the fluid for the patient. When blood from an infected provider is present in supplies that are used for more than one patient, a large number of patients are put at risk for infection.

Contamination Case Studies

Dr. Perz and a colleague, Dr. Melissa Schaffer, decided to review the impact of diversion on infection outbreaks over a 10-year period. Their results were startling.

Between 2004 and 2013, they found six reported outbreaks of infection related to diversion incidents: three involving technicians and three involving nurses. Two of these outbreaks were traced to tampering incidents with opioids administered by PCA pumps, which resulted in bacterial infections.

The other four outbreaks were traced back to cases involving tampered-with vials of fentanyl, which put 30,000 patients at risk and caused 84 patients to acquire hepatitis C. Each individual put at risk had to be contacted and offered appropriate testing to check for hepatitis B, hepatitis C, and HIV.

These cases are grim reminders of just how easily infection can spread when drug diversion is not proactively prevented. Newsweek’s article “Hospital Horror Story” offers insight into tactics used by drug diverters by highlighting the case of a radiology technician responsible for infecting 45 patients with hepatitis C.

Colorado Case

Another less-publicized instance of diversion-related infection was seen in Colorado in 2009. There, two new reports of hepatitis C were submitted—both tracing back to the same hospital. Upon further investigation, it was confirmed that a technician infected with hepatitis C had been recently dismissed upon suspicion of stealing pre-drawn fentanyl syringes left unattended in the operating room.

The worker was using the syringes to inject himself and then replacing the medication with a saline solution for the patient. In doing so, this one individual led to the “recall” of 8,000 patients, and caused18 documented transmissions of hepatitis C.

In these instances of diversion suspicion or conviction, it is important to make sure that due diligence is done not only in catching, but reporting this diversion correctly. Although the individual responsible for the Colorado outbreak is currently serving a 30-year prison sentence, other individuals terminated for their drug use are often able to find employment in other hospitals—allowing them the chance to continue feeding their addiction and risking more patient exposure to infection.


Here are a few suggestions for mitigating infection risks associated with drug diversion.

  • Provide syringes in tamper-evident packaging, so healthcare professionals are better able to tell when a medication has been tampered with.
  • Include someone from infection control in your diversion oversight committee. This person can assist with risk assessment, help determine the source if an outbreak does occur, and work with public health officials if necessary.
  • Consider offering bloodborne pathogen testing to a suspected diverter when doing a drug screen. By treating this as an occupational exposure, testing is done confidentially and will not become a part of the institutional electronic health record.

Diversion presents a substantial risk to patient safety—especially in cases of contamination through injections. The impact goes far beyond the number of patients infected. Those who may have been exposed to the infection have to face the uncertainty of wondering if they are carrying the infection, and many lose their faith in the healthcare system’s ability to protect them. Healthcare providers need to proactively manage diversion to help avoid tragedies that occur through the spread of infection.

Dr. Joseph Perz is the Quality Standards and Safety Team Leader for the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention. During his 15+ years with the CDC, Dr. Perz has guided dozens of outbreak investigations and special studies, drawing attention to the needs for injection safety and other basic infection control practices.

For More Information:

The CDC website is a great resource for those looking to learn more about the rise of infections from drug diversion. It contains a summary of the U.S. outbreak experience, prevention materials, and other resources assembled nationally to address this problem.

View our previous post on diversion here.

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

Download our infographic: How Much Harm Can a Single Diverter Cause in Your OR?

Learn about Omnicell solutions for detecting diversion here.


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