Standardize a Diversion Response Plan

July 2022 - Vol.19 No. 7 - Page #2
Category: Diversion Products

A key part of any successful drug diversion prevention and response program is utilizing a meticulous and impartial response process following each instance of known or suspected diversion. When a colleague is suspected of diverting, it can be difficult to maintain an objective attitude during the investigation and response. It is essential that a formal structure be in place to conduct an impartial investigation and ensure a consistent response.

Building a Multidisciplinary Team

When suspected drug diversion occurs, it is imperative that the investigation and response processes be guided by a multidisciplinary response team to ensure a thorough investigation. The inclusion of members from different departments and specialties on the team will provide a variety of perspectives, helping to ensure all avenues are considered before deciding on next steps. In our experience, having a diverse team brings up questions and concerns that an individual investigator might not consider. This allows for a more in-depth investigation. Additionally, a multidisciplinary group offers insight into different practices that can balance potential knowledge deficits of individuals. Often, team members with relevant experience can help identify education requirements and content for teammates after an event. Once it has been determined that drug diversion has occurred, the next steps should not be the sole decision of a single individual or department, but rather the responsibility of the response team as a whole.

Team Membership

When developing a multidisciplinary response team, it is important to account for the circumstances it will be operating under. The team should be composed of individuals who are available to convene at unscheduled times. Consider including representation from the following departments:

  • Diversion Officer or Specialist: The diversion specialist is responsible for leading the team since they are the member with the most in-depth knowledge of the issue. The diversion specialist communicates with the suspected teammate’s manager before convening the response team to ensure the investigation phase is complete. Final steps in the investigation phase may include requesting staffing assignments, getting the manager’s perspective on the individual’s performance, and seeking responses to any unanswered questions. The diversion specialist is often responsible for interviewing the suspected teammate, always in the presence of a manager or supervisor, and speaking with any relevant witnesses.
  • Human Resources: A human resources (HR) representative is an intrinsic part of the response team. The HR representative has access to personnel information such as hire date and previous performance issues and can guide the response team to maintain compliance through disciplinary processes. Following the outcome of the case, the HR representative is available to assist the suspected teammate’s manager in making the final decision regarding employment.
  • Employee Health: The employee health representative is responsible for facilitating the drug screening process and can help procure an available technician to conduct the drug screen, which is especially important in an after-hours situation.
  • Security: In most organizations, the security department has a permanent spot on the response team. Security can retrieve badge access reports, camera footage, and other information that may be needed for further investigation. They can also terminate badge access when necessary.
  • Pharmacy: Pharmacy should always be represented in the response team. In our health system, we typically include the director of pharmacy from the relevant facility on the team. This ensures pharmacy personnel are aware of the situation and can immediately revoke access to the automated dispensing cabinets (ADCs). When pharmacy is informed at the outset, they can anticipate and comply with time-sensitive state and federal reporting requirements.
  • Nursing: The nursing representative can help ensure the proper questions have been asked regarding workflows and education.
  • Risk Management/General Counsel: The general counsel or risk management representative is responsible for identifying potential legal issues and providing assistance in identifying and reporting patient harm.

Depending on the nature of the case, it may be necessary to add specific expertise to the team, such as an anesthesia leader if the suspected diversion involves anesthesia personnel, or a research compliance officer if the case involves research drugs. These additions can be made on an ad hoc basis.

Surveillance and Monitoring

By its name, one may assume the response team is only activated when a diversion event is suspected. Ideally, the talents of this team should also be utilized in the greater effort of diversion prevention. The response team members should conduct risk rounds in their respective areas to ensure security and compliance with the handling requirements for controlled substances. They should be aware of regulations specific to their areas and inform the drug diversion prevention team of any changes or additions to laws and regulations affecting the handling of controlled substances. They can also serve as the conduit between the diversion prevention team and individual departments to build awareness of the drug diversion prevention program and to encourage reporting of possible diversion events or concerns.

Additional monitoring processes should encompass scheduling department-specific controlled substance inventories. For example, inventories of controlled substances should be completed at least monthly within the pharmacy, while nursing and anesthesia should perform controlled substance inventories of ADCs at least weekly. All departments should monitor for discrepancies on a per shift basis. In the pharmacy and outpatient clinics, the purchasing and receiving of controlled substances should be segregated duties, which are then verified by an objective individual.

Larger scale diversion monitoring should include ongoing auditing and monitoring of controlled substance transactions across the facility. At a minimum, review discrepancies and discrepancy resolution reasons, overrides, transactions by temporary users, null or cancelled transactions, and transactions for temporary patients. Additionally, evaluate usage trends, and review transactions against the medication administration record (MAR) to ensure the medication was administered according to the provider’s orders, and review waste documentation as applicable. A thorough transaction review should also consider timing: were the controlled substances administered and wasted in a timely fashion, or were there delays that could facilitate diversion? All medications should be included in the outlier transaction review so suspicious patterns, such as pairing acetaminophen and an oral opioid, can be identified. Pain assessments also warrant additional review; an unchanged or escalating pain score—or no pain score—may be indicative of diversion by the caregiver.

Ideally, clinical leaders will have a role in ongoing auditing of clinical staff; if that is not feasible, the auditing results need to be communicated to clinical leaders so they can promptly address issues relating to poor practice. Poor practice often masks a diversion issue as it is difficult to distinguish deliberate obfuscation from sloppy habits when they are common practice.

All documentation of audits and investigations should be stored centrally so that it is readily accessible in the event of a visit by a regulatory agency, such as the DEA. The documentation should encompass audits conducted by clinical leaders and members of the investigation team, as well as all investigation documents such as drug screen results, witness statements obtained by supervisors, security reports, and video footage.

Responding to Suspicious Data

When potential diversion has been identified, the drug diversion specialist will review the available information and determine the next steps. Before formally convening the entire response team, the diversion specialist should reach out to specific team members to gather pertinent information such as witness statements, camera footage, badge access reports, details of previous counseling, and the teammate’s previous and upcoming schedule.

The interview process should be conducted under a set of standards developed by the response team. While the interview parameters will be case-specific depending on the circumstances of the suspected diversion, there are basic considerations that must addressed in each interview:

  • Is the teammate a potential danger to patients?
  • Is there a risk the teammate might self-harm?
  • Does the teammate have an adequate support system outside of work?

Before the interview is conducted, the diversion specialist should meet with the HR representative and the employee health representative to determine the best process for conducting a drug screen and placing the teammate under investigation on administrative leave, as case-specific considerations might affect this process. The interviewer should be aware of any substance use assistance or other benefits offered by the organization, such as an employee assistance program (EAP), paid rehabilitation, etc. As interviews can be an emotional process, use a checklist to guide the process and to help avoid omissions. This process will also help to ensure the teammate is aware of the steps that will be taken. This standardized checklist should include items such as retrieving the employee’s badge, placing them on administrative leave pending the drug screen, and ensuring they do not have any controlled substances on their person, in their locker, or in their vehicle.

Establish a standard process for situations in which the teammate confesses. Consider whether the teammate will be asked for a written statement under these circumstances. To gain a better understanding of the diversion scheme details, ask the following questions:

  • When did the diversion start?
  • How did the diversion occur?
  • What drugs were involved?
  • Did tampering occur?
  • Were medications withheld from patients?
  • Does the teammate have any diverted medications on their person, in their personal property (eg, purse, backpack, etc), or at home?

Create a plan for retrieving diverted drugs from a teammate’s home. Usually, this process will involve working with the general counsel and law enforcement. Furthermore, establish a plan for cases in which tampering is certain to have occurred. This would include steps to obtain consent and then conduct bloodborne pathogen testing of the teammate. Any items retrieved during the investigation should be maintained and considered evidence.

Reporting to Outside Agencies

Strictly outlining who is responsible for each level of reporting is an important step in standardizing the diversion response. Since each state has different requirements, it is helpful to research the local reporting requirements and confirm these with the general counsel representative. Develop a reference table that outlines all required reporting, the entities to whom the report is made, the responsible department, and any required timeframes for reporting. Documents from each investigation, including documentation of internal and external reporting, should be maintained by the diversion specialist in a secure electronic format to ensure they are readily available in the event of an audit by a regulatory agency.


Every organization must decide how teammates who have diverted will be treated. Such decisions are often difficult, and discussions on this topic can become emotionally charged. Because there are many approaches to address diversion, it is important to develop an organizational standard to ensure all cases are handled with consistency. While medical staff, for example, may not follow precisely the same path as nursing staff, the processes should be parallel insofar as is possible. Disparate treatment based on the teammate’s role, pay scale, popularity, or level of education is to be avoided at all costs.

Kim New, JD, BSN, RN, is a specialist in controlled substance security and DEA compliance. She has served as a consultant to healthcare facilities across the country, helping set up and expand drug diversion programs to improve patient safety. Kim works remotely as a diversion program consultant with a large US health system.

Michelle Rice is a drug diversion specialist for Atrium Health in Charlotte, North Carolina. She has conducted numerous audits in the clinical environment with a concentration on the proper handling of controlled substances. Michelle earned her BBA in business management from East Tennessee State University.


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