7 Tips to Prevent Diversion in Health Systems

September 2020 - Vol.17 No. 9 - Page #2
Category: Diversion Prevention

Drug diversion presents a substantial risk to patients, staff, institutions, and the community at large. We know that patients suffer from diversion by being cared for by impaired staff, being deprived of needed medication, and by receiving substituted or adulterated drugs. It is important to recognize that staff also suffers from the effects of drug abuse. Likewise, health care institutions are at risk of regulatory liability and harm to their reputations as a result of diversion. Risk to the community arises when health care personnel divert and leave the facility under the influence of drugs they have diverted.

Given the severe threats posed by diversion to patient, workplace, and community safety, instituting and maintaining a robust drug diversion program is vital. Steps institutions can take include the following:

  1. Develop a formal program to address diversion
  2. Devote sufficient resources to the diversion program
  3. Audit data and the physical environment
  4. Implement robust security measures
  5. Develop policies and procedures
  6. Educate staff
  7. Ensure continuous process improvement


TIP #1

Develop a Formal Program to Address Diversion

Diversion is a unique and complex problem that requires a multifaceted program to be effective. No single approach—whether use of ADCs, end-of-shift medication counts, employee background checks, or analytics report reviews—is adequate to attend to the problem.

An effective diversion prevention, detection, and response program requires an executive level committee, a response team, and a diversion specialist or program manager. The executive committee serves to provide oversight, guidance, and resources. The response team, which should be a small group comprising knowledgeable stakeholders, including the diversion specialist and representatives from pharmacy, nursing, and quality/risk, is tasked with analyzing all potential diversion and ensuring a consistent response. The diversion specialist is responsible for managing the program’s daily operations.

TIP #2

Devote Sufficient Resources to the Diversion Program

A diversion program requires a dedicated leader. With clinical leadership focused on the current pandemic, the need for dedicated diversion resources is more urgent than ever. Relying solely on pharmacy and clinical leaders to maintain a diversion program is not a sustainable approach. While the diversion program requires the participation of many stakeholders within the facility, there must be one individual who assumes accountability for regulatory compliance and the patient and staff safety aspects of diversion prevention and detection.

The role of the diversion specialist is to oversee surveillance and auditing activities, collect suspicious data from across the facility for tracking and trending purposes, provide or direct ongoing staff education, be actively involved in policy development, and convene the Diversion Response Team when diversion is suspected. Ideally, this is a full-time position, and it certainly should be for most facilities. Should a full-time position not be sustainable, a staff member still must be dedicated to this role. In addition, many facilities include one or more analyst positions in their program to undertake routine auditing activities and provide support when an in-depth investigation is required.


TIP #3

Audit Data and the Physical Environment

Every facility must ensure that there is ongoing auditing of controlled substance transactions. While this may seem self-evident, facilities should not make assumptions about the effectiveness of their auditing activities. Unless there is a defined set of expectations, auditing is likely to be perfunctory and variable. Be sure the auditing program fully defines the expectations of regular report reviews, including specifying which reports are to be sent to pharmacy and clinical leaders, what department leaders are expected to do when they receive reports, and how suspicious findings are to be approached.

In addition to auditing data, regularly assess the physical environment. Routine risk rounding in all areas where controlled substances are handled should occur conjointly with transaction auditing. Rounding is essential to identify opportunities for security breaches, burdensome workflows, and lack of staff awareness. Diversion risk rounds must involve observation of areas where controlled medications are received, stored, prescribed, used, and destroyed in order to uncover noncompliance, workarounds, complacency, and knowledge deficits. The main objectives are to evaluate security, staff awareness, regulatory compliance, compliance with institutional policy, and to initiate process improvements where warranted.


TIP #4

Implement Effective Security Measures

Over the past several years I have become aware of a remarkable increase in security breaches leading to diversion. Diverting individuals are clever and highly motivated, and if security is lacking, they will often find a way to achieve their goal.

Security measures must be thoughtful and uniform. Avoid implementing measures sporadically in response to particular events; instead, each breach should be used as a lesson to be applied across the facility to prevent future diversion. Work toward implementing basic security measures, including installing surveillance cameras at all ADCs in non-operative areas, place ADCs in medication rooms whenever possible, and use badge readers at all ADC access points. Cameras should also be placed at all pharmacy entrances and anywhere controlled substances are processed, stored, or destroyed.

Review access privileges to secure medication storage areas regularly. Timeouts to ADCs must be sufficiently narrow to prevent unauthorized access, and all ADCs should be accessed using biometric identification unless there is a verified reason for exemption. In addition, ensure that staff in procedural and operative areas have access to a secure place for temporary storage of controlled substances if necessary.

TIP #5

Develop Policies and Procedures

Diversion policies, procedures, and standard work must be sufficiently detailed so that staff understands exactly what is expected of them. For clinical staff, include detailed direction on how long controlled substances are permitted to be out of secure storage prior to administration or return, when wasting should occur and where residual medication should be wasted, and whether and under what circumstances handing medication off to a colleague is permitted. Make certain that pharmacy policies provide explicit detail on handling expectations from the vault, to stocking, to destruction. Policies for all staff should address proper wasting procedures, including the requirement that witnesses visualize the physical destruction of the medication.

TIP #6

Educate Staff

In order to establish a culture of compliance and accountability, all staff within the facility should receive diversion training appropriate to their role at hire and annually thereafter. Without education, staff may discount the likelihood that diversion will occur, and might assume that diverting staff fit commonly held stereotypes of drug abusers. Furthermore, suspicious events might go unreported despite clear manifestations of diversion.

Education can also help prevent staff from viewing requirements as punitive or excessively burdensome. Presenting diversion in terms of a patient and staff safety initiative will help all staff appreciate that diversion is an ever-present risk in all institutions. Providing diversion education gives staff the tools they need to help reduce opportunities for diversion and to report concerns when they arise. Be sure that education includes information about the scope of the problem of diversion, signs that diversion may be occurring, and information about where and how to report suspicion of diversion or impairment.

TIP #7

Ensure Continuous Performance Improvement

Auditing, risk rounding, and diversion investigations all provide opportunities for performance improvement. Auditing often uncovers evidence of poor practice or noncompliance in controlled substance handling; noncompliance is conducive to diversion and if widespread, may conceal diversion. Therefore, be sure to address all instances of poor practice. Any evidence of workarounds or a lack of security that is identified in risk rounds should prompt the diversion specialist to consider whether other areas may have the same issues. Nearly all diversion investigations provide opportunities for performance improvement—for example, the need for staff education, policy development, better camera placement, and additional badge readers.


Patient and staff safety requires that diversion be prevented whenever possible; hence, it must be detected quickly and handled with effective, uniform procedures. Following these 7 tips will create a safer environment for patients and staff, protect the institution from regulatory liability, and protect the community from the effects of institutional diversion.

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.


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