Uncovering Diversion: 6 Case Studies

January 2018 - Vol.15 No. 1 - Page #12
Category: Diversion Prevention

Preventing diversion in the hospital setting can only be successful when policies and procedures (P&Ps) are in place to ensure controlled substances are stored securely, and when staff members are compliant with those P&Ps. Staff must have a clear understanding of why it is important to follow P&Ps, lest they regard the procedures as unduly burdensome.

The following collection of cautionary anecdotes illustrates the necessity of establishing procedures to keep controlled drugs secure and promote accountability. Although identifying information has been removed and the names are fictitious, these stories are true accounts of diversion that has occurred in US hospitals. It is hoped that these case studies will be a useful tool to educate reluctant staff on the critical nature of complying with P&Ps.

 Case Study 1 
Can You Help Me Out?

Bob is an outstanding nurse in the cardiac step-down unit, where he has worked for 6 years. He is always upbeat and helpful, has a great sense of humor, and is friendly toward all of his colleagues.

While with a patient, Bob asks his colleague, Mary, to pull a hydromorphone PCA from the ADC for him. Bob states that he is busy with the patient and the PCA is about to run dry. Mary is happy to help, and complies with the request. On another occasion, Bob asks Jim to bring him a hydromorphone PCA because he is caring for a patient and is unable to leave the patient’s room.

Bob’s requests occur with increasing frequency. His colleagues are always willing to pull hydromorphone PCAs for him and never suspect that he might have an ulterior motive, as he is clever enough to reach out to a different colleague each time he asks for help. Ultimately, Bob is receiving an average of 5 to 6 hydromorphone PCAs from peers each shift; few of these are actually administered.

The day arrives when Bob asks colleagues for so many hydromorphone PCAs that the ADC is depleted. Pharmacy is notified that additional PCAs are required. The pharmacist in charge finds this highly unusual and runs a report of hydromorphone removals for the day, cross-referencing them with the medical record to confirm administration. None of the PCAs are documented as administered. The pharmacist contacts the charge nurse and learns that Bob is caring for all the patients involved. Further investigation reveals that Bob has been using his colleagues to divert hydromorphone PCAs for personal use.


• Staff must pull their own controlled medications.
• Handoffs of controlled substances dilute accountability and can facilitate diversion; thus, they should only occur in emergent situations. If a handoff is necesary, the staff member who pulled the medication is responsible for that medicatoin, and should review documentation of administration prior to the end of the shift to ensure the drug was administered near the time it was removed.

 Case Study 2 
Can You Sign Off On This?

Jane begins working in the emergency department (ED) of a busy trauma center affiliated with an academic institution. In this facility, it is common practice for nurses to enter orders via CPOE, including orders for controlled medications. Physicians review all orders that are entered by clinical staff, and if the details are correct, they electronically verify these orders.

Jane quickly befriends most of the medical staff in the ED. Within a few months of starting her new job, she begins entering orders for morphine into the CPOE system for patients who have just been discharged. Over time, Jane begins entering orders for morphine for patients who have been discharged hours earlier. After many months, Jane has input orders for morphine for hundreds of discharged patients. The physicians verify every order without questioning the details.

Ultimately, Jane’s need for morphine becomes so great that she begins pulling morphine indiscriminately from the ADC for patients that are present in the ED, but are being cared for by other staff. In her haste during one transaction, Jane creates a discrepancy, and the charge nurse is called to help resolve it. When recent transactions are reviewed, it becomes apparent that duplicate doses of morphine have been pulled for several patients. Further review reveals that the patients’ assigned nurses pulled the initial doses, while Jane pulled the duplicate doses.

Jane is questioned and states that she was just helping and did not realize that her colleagues had already pulled the doses. While this might occur on occasion, the charge nurse points out that a pattern exists of pulling duplicate doses for other staff members’ patients. Jane ultimately confesses to diversion.


• Before verifying an order that has been entered by clinical staff, physicians and midlevel providers should carefully review the details. If the order is not consistent with the provider’s care plan, it should be rejected.
• As part of their routine surveillance, diversion auditors should review all rejected orders involving controlled substances.

 Case Study 3 
Check the Trash

Kate is the inpatient pharmacy director for a large hospital. She relies on Joe, her star lead narcotic technician, to run the closed-loop report after each shift and ensure that all medication discrepancies are addressed.

Joe is a well-respected, 25-year employee of the hospital. He is extremely possessive of all tasks relating to controlled substances; his peers assume he is simply a perfectionist. Joe helps with purchasing, stocking controlled substances in the electronic vault, conducting inventories of the electronic vault, and stocking ADCs. Joe is the sole employee to work with the reverse distributor’s representative when expired stock is collected.

On his drive home from work, Joe is involved in a car accident. Due to his injuries, he is out of work for several months. Shortly after the accident, the reverse distributor’s representative comes to collect medications. With the staff uncertain as to how to proceed, Kate becomes involved. To her surprise, there are only a handful of controlled substances waiting for pick-up. Kate investigates transactions and realizes that Joe has been removing controlled substances from ADCs and has been pilfering stock awaiting destruction.


• Medications awaiting destruction should be received into stock and counted in routine inventories until they are picked up.
• A supervisor should reconcile all reports of controlled substance stock collected by the reverse distributor to verify that the items collected match what is listed.
• Inventories should always be performed by two staff members.
• Maintain separation of duties in procurement, receiving, and stocking.
• One staff member should not have full control over controlled substance purchasing and handling.

 Case Study 4 
Always Sign Out of the ADC

Julie works at a small hospital, as part of a correspondingly small staff of CRNAs, who operate under the supervision of one of three anesthesiologists. The CRNAs and anesthesiologists are all part of a single anesthesia group. The hospital staff are extremely close-knit and trust each other implicitly. Anesthesia staff obtains the necessary drugs via biometric access from a central ADC before each case. Because Julie is so comfortable with her peers, she has fallen into a habit of failing to sign out of the ADC after each transaction.

One afternoon, a woman presents at the hospital in labor and there are complications. The CRNA assigned to the case is concerned and summons Paul, the anesthesiologist in charge, for assistance. Paul is in his 60s and has worked at the hospital his entire career. When the CRNA knocks on the call room door and does not receive a response, she notifies a security officer, who opens the door and finds Paul unresponsive with an IV in his leg and an empty fentanyl vial nearby.

In the ensuing investigation, it is discovered that Julie removes four times as much fentanyl from the ADC as her peers; only a few transactions are recorded for each of the anesthesiologists. Julie is upset when interviewed and denies removing all of the fentanyl that has been logged under her user ID, but is unable to explain the transactions. She is asked to consent to a drug screen, complies, and is then suspended indefinitely. Fortunately, Paul is resuscitated. He learns what has unfolded and admits to diverting fentanyl under Julie’s user identity. Paul states that Julie is an easy target because she reliably fails to sign out from the ADC.


• ADC users must sign out each time a transaction is complete and any time they step away during a transaction. A user who fails to sign out is accountable for transactions that occur under their sign-on.
• Implicit trust of colleagues is a factor in many diversion cases.

 Case Study 5 
Do Not Be Afraid to Speak Up

Kathy is the day shift charge nurse on a surgical intensive care unit. A charge nurse for many years, she is considered highly skilled in caring for critically ill patients. Jose is a new nurse graduate who starts working on the unit as an orientee. Jose is usually supervised by Kathy or David, another day shift charge nurse.

One day when Jose is returning from a break, he sees Kathy leaving one of his patient’s rooms. Jose is uncertain why Kathy had been in the room, but he finds his patient asleep, and since the patient’s condition appears unchanged, he does not question Kathy. Over the next month, Jose witnesses several similar events when coming back from a break or lunch. One time, he runs into Kathy as she is leaving his patient’s room. He asks if everything is okay, and she explains that the patient was in pain and needed a bolus dose of fentanyl. Jose finds this information odd, as the patient had been doing well on the fentanyl drip he started.

The next day, Jose sees Kathy leaving his patient’s room as he returns from lunch. He becomes suspicious and carefully inspects his patient, noting that the fentanyl drip had more volume than it had when he left for lunch earlier. Jose is reluctant to say anything and remains silent for the remainder of his shift. However, by the time he gets home, he is so upset he calls his nurse manager and relates the day’s events and his suspicions regarding Kathy’s presence in his patients’ rooms over the past few months.

Jose learns the next day that several patients on fentanyl drips had been showing signs of inadequate pain relief over the prior day. He realizes that if he had spoken up sooner, patients might have been spared going without appropriate pain relief. Immediately following her call with Jose, the manager had instructed staff to remove all fentanyl drips and have the pharmacy provide replacements.

Several weeks later, the manager informs Jose that the removed drips were sent out for testing and were found to be diluted. Kathy is questioned, resigns in lieu of undergoing a drug screen, and is reported to the State Board of Nursing. Review of patient records does not reveal conclusive evidence that the patients suffered unrelieved pain. Due to the possibility of tampering, patients are monitored for infection with bloodborne pathogens.


• Before administering medications, inspect them to ensure they are intact and appear to contain the correct drugs.
• Nurses should not be afraid to ask questions and report suspicious activity they observe. It is not necessary to be certain that diversion is occurring before making a report.
• If tampering is suspected, it is important to recognize that all stock may have been impacted. Obtaining replacement medications from the pharmacy can help protect patients.

 Case Study 6 
Keep the Door Closed

Staff in a busy endoscopy unit are caught propping the medication room door open, compromising medication security. When they are told that the door must remain closed, they say they will comply, but complain that the physicians require a brisk pace, and having to use their badges to sign into the medication room is time-prohibitive. After the first warning, staff is repeatedly caught with the medication room door propped, so the unit manager threatens to discipline anyone caught propping open the door.

Tina and Sam are working late one day and have the door propped open, as usual. When they see the manager walking down the hall, they quickly close the medication room door. Beth, the unit clerk, observes the situation and offers them some advice. Pointing to a pile of refrigerator magnets the hospital developed for marketing purposes, Beth shows them how to place a magnet at the latch area of the door, thereby preventing the latch from engaging. Tina and Sam feel this is a brilliant solution, as the door would appear to be closed but the latch would not be engaged, enabling them to come and go without having to scan their badges. Tina and Sam tell the rest of the staff about the workaround, and soon everyone is using the magnet trick.

One weekend several months later, an impostor approaches an environmental services staff member and asks her to badge him in to the closed endoscopy unit for the purpose of changing the air filters. Without hesitation, the staff member badges the man in. Since the medication room door is propped open with a magnet, the impostor is able to enter the medication room without difficulty, physically break into the ADC, and steal all of the controlled substance stock.


• Medication room doors should be kept closed and secured to prevent unauthorized access.
• Bypassing drug security mechanisms can facilitate diversion, even if the workaround is not intended for harm.
• Staff should never let anyone without authorized access into a secure area. Rather, the individual should be referred to security to obtain permission to enter.


Developing robust P&Ps is necessary to prevent diversion, but simply ensuring they are in place is not sufficient. Staff must understand the rationale behind the P&Ps; otherwise compliance may suffer. Education on the elements of the P&P, as well as the reasons for each strategy, will improve compliance and help prevent the outcomes illustrated in these stories. Using real case scenarios is an meaningful way to educate staff and affect change.

Kimberly New, JD, BSN, RN, is the founder of Diversion Specialists, LLC, a consulting service providing solutions for all aspects of institutional drug diversion. She is a specialist in controlled substance security and DEA regulatory compliance, working with health systems across the country to establish and expand drug diversion programs, with the overriding goal of improving patient safety. Kim is also the cofounder and executive director of the International Health Facility Diversion Association.


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