Drug Diversion - Now it's a Problem!

You may have heard me say it before. "It's not a problem, until it's a problem." And every time I think I've said all there is to say about this topic, drug diversion rears it's ugly head and I'm back on this subject again. Earlier this year I reported the incredible increase in diversion cases over the last year (128% increase from 2017-2018, CBS Nightly News). It seems that national media and The Joint Commission are finally becoming aware of what we've known is a problem for years. I've recently come across reports from the popular internet news outlet Gizmodo and from a Joint Commission update, both shining a spotlight on diversion. These articles include important lessons that I'd like to share with you today.

The Joint Commission recommends that first and foremost, you have an antidiversion plan and you stick to it! Ask yourself these questions and evaluate how secure your facility is against diversion risk:

  • Does your center have a diversion prevention policy? If so, have your staff seen it and do they know you're actively preventing diversion?

  • Who is in charge of the diversion prevention plan?

  • Do you perform monthly audits or inspections designed to target diversion risk factors?

  • Do you generate reports on diversion prevention efforts and report them to your center's board or QAPI?

The article from The Joint Commission detailed diversion events in which staff were able to circumvent automated dispensing cabinet (such as Pyxis) safeguards and controls to access controlled substances illegally. In some cases, the drawers remained active or open even after users had logged out, meaning that they could be re-opened and accessed without it being recorded in the computer's log. In other instances, managers weren't alerted to manual overrides in the dispensing cabinet system. Other times, no one was performing audits of the cabinets or override report, so the diversion went unnoticed for lengthy periods of time. A diversion event in New York in 2018 included a nurse diverting drugs intended for patients AND inappropriately accessing the automation cabinet (GIZMODO, "A Nurse's Alleged Opioid Theft Led to a Blood Infection Outbreak at a New York Hospital"). In this case, the nurse took medication out of the automated cabinet, but she also self injected the liquid pain medications intended for the patients, replaced the vial contents with saline, and contaminated the vials. The patients were administered that tainted tap water, were denied much needed pain relief, and exposed to a blood borne pathogen. The diversion incident was discovered because multiple patients in this cancer treatment ward were infected with a rare blood disease, and the investigation revealed that the only common thread was the nurse who cared for all patients.

In the case of diversion, the best defense is a good offense. Prevent diversion in your facility by taking an active approach. Check your facility policies and keep your eyes open and ears to the ground. Here are a few tips for making diversion just a little more difficult at your center:

  • Remove controlled substances from their locked storage as close to time of use as possible

  • Never allow practitioners to carry "just in case" doses, vials, or syringes

  • Never pass off controlled substances to another person to waste for you, or accept it from another practitioner to waste

  • Use sharps containers with small openings so it's difficult for potential diverters to reach into the containers

  • Install video surveillance in areas at high risk for potential diversion, including controlled substance storage areas

  • Rotate staff who handle controlled substances and if possible, do not allow the same staff member to have complete control over all controlled substance inventory, handling, and management

  • Don't allow bags or backpacks in controlled substance storage or handling areas

  • Limit staff who have access to controlled substances in your facility


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