Resources for Standardizing Diversion Management

February 2016 - Vol.13 No. 2 - Page #12
Category: Automated Dispensing Cabinets Monitoring Software

Drug diversion by health care personnel is a crime whose victims include patients, the diverting staff member, colleagues of the diverter, the institution in which the diversion occurs, and the community. Diversion almost certainly occurs at every institution that handles controlled substances, and the rate of discovery of diversion events has increased steadily over the past decade.

Although regulations exist for diversion prevention and detection, as well as response mechanisms, ambiguity surrounding governance leaves many facilities grappling with exactly how to approach the issue and garner upper management support for a proactive program. Furthermore, institutional response strategies and issues such as confidentiality sometimes hinder open discussion. As a result, many facilities have separate internal standards for nursing and pharmacy and lack a uniform approach across institutions and across state lines.

Given the seriousness of the problem, a need exists for the development of tool kits, guidance documents, and training resources to help facilities build strong, standardized diversion-prevention programs. Health care institutions share the common goal of providing effective care in a safe environment. As such, they should be willing to collaborate and openly share best practices in the effort to identify measures that help ensure the safety of patients and staff, while reducing the risk of diversion.

Coalitions and Resources

If there is a silver lining to previous cases of patient harm due to diversion, it is that they have increased awareness of diversion and prompted the development of multiple stakeholder coalitions and resources for health care facilities, including:

  • Drug Diversion Booklet: In March 2011, the Missouri Department of Health and Senior Services’ Bureau of Narcotics and Dangerous Drugs produced the publication, Drug Diversion in Hospitals: A Guide to Preventing and Investigating Diversion Issues ( The booklet, which is divided into sections on prevention, supervision, investigation, and administration aims to educate facilities, assist them with the development of policies and procedures, and provide information on state and federal regulations and liability issues.
  • Road Map and Toolkit: In May 2011, the Minnesota Department of Health and the Minnesota Hospital Association entered into a partnership with members of the health care and law enforcement communities to address the issue of drug diversion in health care institutions in Minnesota. The effort was initiated in the wake of several high-profile diversion cases in the state, some involving patient harm. The final report of that partnership was published in March 2012 ( and included historical and background information on institutional diversion, a road map of best practices to prevent diversion, a flow chart of reporting requirements for cases of diversion in Minnesota, and a toolkit of resources for institutions seeking to improve their diversion-prevention programs.

The Minnesota Road Map ( is in the form of a checklist. Assessment questions are organized into components including: organizational structure, access to data for reporting, facility expectations as demonstrated in culture and policies, and staff and patient education. A second section on medication handling covers drug storage and security, procurement, prescribing, preparation and dispensing, administration, wasting, monitoring of controlled substances, and the handling of suspected diversion. In all of these components, the road map emphasizes consistent processes and adherence to policies.

The Minnesota Toolkit ( is a compilation of various resources for institutions, including a sample job description for a diversion-prevention coordinator, a list of Minnesota statutes and regulations related to diversion, a worksheet for monitoring records for evidence of diversion, a variety of educational resources, and links to websites and individuals with unique insight or expertise relating to diversion. All of the resources in the Minnesota Controlled Substance Diversion Prevention Coalition’s report can be applied or adapted to facilities in other states. In fact, many facilities around the country use the road map to perform an initial gap analysis in preparation for developing a robust diversion program.

Many entities have developed resources for addressing diversion and a vast array of information is available. At least partly in response to cases in which patients were harmed by health care personnel who diverted drugs, departments of public health across the US have created statewide multidisciplinary task forces devoted to providing tools for hospitals. Among the various resources are the following:

  • Infection Risk Graphic and Blog: The Centers for Disease Control and Prevention (CDC)’s Injection Safety page ( added information on diversion, including a graphic that illustrates the risks of contracting an infection when a health care provider diverts injectable drugs either through tampering or substitution. The CDC’s Safe Healthcare Blog ( also has several posts on the risks of drug diversion by health care personnel, which serve to educate health care workers, as well as the general public.
  • Diversion Workgroup: Recognizing that drug diversion by health care staff is a public health problem, the Council for State and Territorial Epidemiologists ( formed a diversion workgroup that gathers information from various sources across the country to assess awareness, develop diversion-prevention tools, and help forge sustained working relationships between health care facilities and public health officials.
  • Statewide Coalition and Practice Exercise: In New Jersey, attendees of a drug diversion conference in June, 2015, which was co-sponsored by the New Jersey One and Only Campaign, wanted more information about drug diversion and sought help in developing prevention policies. Seeing benefit to sharing experiences and best practices, they launched the New Jersey Coalition (, which, in partnership with licensing and regulatory authorities, developed a practice exercise consisting of a set of instructions for facilities to conduct practice sessions in a classroom setting. The exercise allows health care facilities to assess their performance on various diversion-related measures in a confidential manner without the fear of being penalized.

The coalition will be piloting the exercise in several acute care facilities within the state. The results of the self-assessments are expected to provide the coalition, and state and federal partners, with information on best practices and lessons learned, and enable the coalition to develop a facilitator discussion guide. In addition, the New Jersey One and Only Campaign posted numerous resources on its Web page, including print, audio, and video information; toolkits; posters; etc.

  • Video Education for Staff: The Colorado Department of Health’s One and Only Campaign ( has been an active proponent of diversion education for some time. With a focus on developing resources for health care personnel, their latest tool is a digital storytelling video featuring Lauren Lollini, a patient advocate and a victim of diversion. By exploring multiple aspects of the diversion event, the story helps health care workers better understand the issue, particularly the connection between drug diversion and infection transmission. The video, which will be available for viewing in the near future, includes information about the scope of the problem, outlines diversion-prevention strategies, and addresses the responsibilities of public health officials and hospital departments when cases are identified.
  • Podcast on Diversion and Tampering: Last summer, the New York One and Only Campaign ( produced a podcast ( on health care provider drug diversion and the effects of tampering and substitution. The podcast features a discussion led by New York State Department of Health Commissioner Howard Zucker, MD, JD, and explores how diversion contributes to unsafe injections, how facilities can spot potential diverters, and how individual practitioners can impact workplace and patient safety through vigilance when diversion becomes a concern. For a complete list of resources, visit
  • Collaborative Stakeholder Group: This past fall, the North Carolina Division of Public Health’s Communicable Disease Branch ( launched a stakeholder group to support drug diversion awareness. Participants include representatives from state licensure boards, state and local law enforcement, health care facility risk management and infection prevention departments, and various professional associations. The group’s purpose is to discuss strategies for detection and prevention of drug diversion and to develop resources for use by health care facilities statewide.

Nationwide Standardization

These excellent efforts undertaken by various states underscore the need for even greater standardization. Establishing best practices and providing access to effective diversion-prevention tools in a piecemeal fashion will produce limited benefits. Recognizing the need to move beyond the state-by-state approach and develop national best practices, professional organizations also have begun to tackle the issue of diversion by health care personnel.

  • The Association for Healthcare Internal Auditors ( has a regular section on diversion in its newsletter, features a column on diversion in each edition of its digital and print magazines, and has developed an online educational module on the topic for its members that covers how to do a physical diversion risk audit within a health care facility. The interactive module includes a checklist tool and a post-test.
  • Public health departments, private entities, and non-profit professional associations regularly offer training about drug diversion by health care personnel. The newly formed International Health Facility Diversion Association ( is focused entirely on this issue. IHFDA will hold its first annual conference September 13-14, 2016, in Cincinnati, Ohio, and will provide forums for discussion and problem solving, as well as a series of ongoing Webinars. The first Webinar will be a Healthcare Facility Diversion 101 course meant to introduce new investigators to the topic and to serve as a refresher to more experienced investigators. The second webinar will be on Security and Accountability in the Remote or Retail Pharmacy. Future topics will include Diversion in the Long Term Care Setting, and Diversion Prevention and Detection in the Home Health Setting.
  • The American Society of Health-System Pharmacists ( has begun work on the development of universal guidelines for health care facilities on diversion-prevention, detection, and response policies. Although a projected completion date does not yet exist, this is a priority project for ASHP.

Working Together

There is substantial risk associated with diversion by health care personnel, as this activity endangers patients, while placing the lives and reputations of diverters at stake. Individual facilities should not fight the battle alone. By working together, health care facilities can develop strategies to reduce the likelihood that diversion will occur and address it effectively when it does.

Kimberly New, JD, BSN, RN, is a specialist in controlled substance security and DEA regulatory compliance and consults with health care facilities across the country. Kim works with health systems to establish and expand drug diversion programs with the overriding goal of improving patient safety.

Kimberly New is a frequent contributor to PP&P.
Her other articles include:


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