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Drug Diversion: A Threat to Hospital Safety

 |  By PSQH  
   September 19, 2019

The Joint Commission issues recommendations to prevent drug diversion at hospital facilities.

The full version of this article by John Palmer originally appeared on PSQH.

Amid an expanding problem of illegal opioids and a growing concern over abuse and theft by hospital staff, The Joint Commission has released advice and guidelines for preventing drug diversion in facilities.

The alert newsletter, Quick Safety 48, was released in the April issue of The Joint Commission Perspectives, in which it cited statistics from both the U.S. Substance Abuse and Mental Health Services Administration and the American Nurses Association, that suggest 10% of healthcare workers in the U.S. are abusing drugs.

The Joint Commission said diversion of opioids is seen across all levels of an organization, from chiefs to frontline staff, and across all clinical disciplines. Only a fraction of those who divert drugs are ever caught, The Joint Commission noted, "despite clear signals such as abnormal behaviors, altered physical appearance, and poor job performance. Direct observation is vital to detecting diversion and may be the only way to identify an impaired colleague."

"Leaders have a responsibility to establish processes that support staff while enabling rapid detection of diversion," said The Joint Commission.

Signs of diversion to look for

The Joint Commission recommended that drug surveillance programs start with noticing patterns and trends in drug utilization. Quick Safety 48 listed the following behaviors or indications to watch for:

  • A nurse removes controlled substances without a doctor's orders, for patients not assigned to that nurse, or for recently discharged or transferred patients
  • Product containers are compromised
  •  A substitute drug is removed and administered while the controlled substance is diverted
  •  A verbal order for controlled substances is created but not verified by the prescriber
  •  Prescription pads are diverted and forged to obtain controlled substances
  •  A prescriber self-prescribes controlled substances
  •  Volume is removed from a premixed infusion
  •  Multidose vial overfill is diverted
  •  Prepared syringe contents are replaced with saline solution
  •  Written prescriptions are altered by patients
  •  Medication is documented as given but not administered to the patient
  • A provider has excessive pulls for PRN (as-needed) medications compared to his or her peers
  • Drug dispensing machines show discrepancies or overrides
  • Wasting of medications is not adequately witnessed
  • Controlled substance waste is removed from an unsecure waste container
  • Controlled substance waste in a syringe is replaced with saline
  • Expired controlled substances are diverted from a holding area
  • Patients continue to complain about excessive pain, despite documented administration of pain medication
  • Potential falsification of medical records, indicated by late documentation of certain medications only or by coworkers assisting others in completing documentation
  • "Batching" assessments and treatments for pain
  • Frequent efforts by a particular nurse to help other nurses administer pain medication

What can be done?

The problem with drug diversion is that hospitals often don't have an effective prevention and accountability program in place. Abusers learn how to circumvent processes to fit their needs, which frequently puts patients at risk of harm.

What's more, if the abuser is discovered, the hospital often allows the person to simply resign from his or her position, which then permits the person to get a job at another hospital and repeat the pattern of diversion.

"Many times I find in institutions where they've had, for instance, a lack of auditing for a period of time, that diverters will test the system—and when they find that they can divert undetected, they can become very, very bold. That comes primarily from lack of reporting diversion," says Kimberly New, JD, a nurse, attorney, and consultant specializing in helping hospitals prevent, detect, and respond to drug diversion. New also helped The Joint Commission develop the latest guidelines.

In the Quick Safety report, there are several suggestions for tackling the problem of drug diversion in hospitals:


1. Make prevention your primary goal. If your employees know you're watching and holding them accountable, they will think twice about attempting to steal drugs. Healthcare facilities must have systems to facilitate early detection. The Joint Commission suggests video monitoring of high-risk areas, active monitoring of pharmacy and dispensing record data, and remaining alert for behaviors and other signs of potential diversion activity. Teach your employees to follow the mantra: "See something, say something."

2. Even your best employees might be diverters. Diverters don't fit commonly held perceptions or stereotypes of individuals who are stealing and abusing drugs, which is important for staff to understand when watching for diversion activity.

3. Consider how easy it is to obtain medications. Diversions can happen in places with little supervision of nurses or overnight shifts where nurses know no one would be holding them accountable for the medications they are dispensing to patients. Ensure you have safety protocols in place on all shifts, in every unit, and hold every staff member accountable.

4. Beware of agency nurses or temps. Many hospitals employ nurses contracted by outside agencies, many of whom work in several hospitals at once. This not only gives diverters more access to drugs, but it also makes it harder to get caught. In some cases, agency nurses are not held to the same standards as hospital employees.

John Palmer is a freelance writer who has covered healthcare safety for numerous publications.

Patient Safety & Quality Healthcare’s mission is to provide news, science, research, and a forum for opinion for clinicians, healthcare professionals, and everyone interested in improving quality in healthcare. Learn more.


Opioids are the most commonly diverted drug among healthcare professionals.

To prevent diversion, healthcare facilities must design a comprehensive diversion plan.

A diversion plan must be audited to uncover loopholes.

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