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June 30, 2021

Strategies for Preventing Hospital Drug Diversion

Kim Dove, PharmD
Senior Pharmacy Consultant, Omnicell

We all understand the harm that controlled substance drug diversion can cause to patients, the healthcare institution, and of course, to the diverters themselves. Grappling with drug diversion requires ongoing vigilance and effort, but with smart strategies in place you can deter diversion and the damage it inflicts.

Creating a diversion prevention program led by a multidisciplinary diversion committee to develop, refine, and communicate diversion prevention policies is the first step. Having this team in place helps to establish a culture of diversion awareness and prevention. Among other proactive steps, they will look for gaps in chain of custody throughout the medication management process. Following are some strategies to consider for several touch points along the medication use path.

Chain of custody starts at the receiving dock

The ASHP Guidelines on Preventing Diversion of Controlled Substances call for separation of duties between the ordering and receipt of controlled substances.

Consider your practices for entering new medication shipments into inventory. Is the same person who is receiving the inventory also responsible for counting and stocking in the controlled substance vault?

Ideally you want to assign different people to different parts of the process, or at least include a witness during the stocking process, for example, to help mitigate risk.

Tightening security in the OR

The operating room is another area where security may be compromised. Many ORs still use manual carts with locks that are not unique to the user, resulting in common knowledge of the combination or shared keys, making access to controlled substances much easier.

If automated anesthesia carts are used for medication dispensing in the OR, they should not be left open/unlocked while unattended to minimize the opportunity for unauthorized access. ORs can often be chaotic, especially in between cases with cleaning and restocking, increasing the opportunity for unauthorized access and diversion opportunity.

Ensure that the anesthesia cart is locked and logged off in between cases. It’s also a best practice to make sure the auto log off times are in compliance with federal, state, and facility policies if the user does walk away prior to exiting the system.

Best practices in nursing units

In the course of my experience, I’ve seen vast improvement in the storage of oral and injectable controlled substances in automated dispensing cabinets on the nursing floors. Every transaction is traceable down to the medication and the lockable bin where that medication is stored. Advancements in biometrics also help with diversion prevention by eliminating the problem of user IDs and passwords being shared or stolen.

Institutions should take advantage of the best practices settings provided by their ADC partner, and review the settings regularly to ensure inadvertent changes weren’t made that could increase the chance of diversion. Witnessing should also be considered for processes where increased risk of diversion may occur – including waste, return, and restocking tasks.

Another significant improvement in diversion detection is the availability of data that pharmacy analytics software can provide. Many processes that were once manual and very labor intensive are now automated based on real-time data. This allows for proactive monitoring and facilitates the review of actions and transactions that may be indicative of suspicious activity.

Discrepancies: Say what you do, and do what you say

The diversion program should have a well-defined policy for managing controlled substance discrepancies, and staff should be aware of the expectations to comply with them. In addition to following federal and state guidelines, a good discrepancy policy should address accountability and timing for reporting (such as end of shift or within 24 hours), and include a process for following up if a discrepancy can’t be resolved in that time frame.

When discrepancies are not reported in a timely manner it often becomes difficult to track the chain of custody, and potential diversion incidents may go unnoticed.

End of the line: Expired controlled substance waste

How are controlled substances stored and accounted for when they’ve expired? Your diversion prevention policies should also address this part of the medication use process.

If you’re storing expired controlled substances in the narcotic vault or a Controlled Substance Manager cabinet, ideally keep them segregated in a separate zone from the dispensing area, preventing easy access when new medications are retrieved. Requiring a witness when that zone is accessed is also a good policy.

Check and balances

Preventing diversion takes ongoing vigilance at every level and every touchpoint, but the stakes are worth the effort. A strong diversion program with a tight chain of custody for controlled substances is an imperative for avoiding tragedy. Keep yourself, your patients, and your healthcare institution safe with built-in checks and balances at every step along the medication management process.

Learn more about strategies for preventing drug diversion in this Pharmacy Practice News article.


The views and opinions expressed in this blog are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer or company. Assumptions made in the analysis are not reflective of the position of any entity other than the author(s). These views are always subject to change, revision, and rethinking at any time and may not be held in perpetuity.

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