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Three Elements of Organizational Drug Diversion Programs


By Robert Campbell, PharmD, director, Clinical Standards Interpretation Hospital/Ambulatory Programs, and director, Medication Management
Earlier this month, I blogged about drug diversion and its implications in the healthcare profession. With a 166% increase in opioid diversion in 2018 from the year prior, it’s clear that prevention needs to be a top priority.
Now, I’m back to shed light on how to prevent drug diversion in your organization.
Even the best efforts have not completely eradicated diversion. Diversion prevention requires continuous prioritization and active management to guard against complacency.
There are three essential components health care organizations need to consider when dealing with drug diversion: prevention, detection and response.
  1. Prevention. Health care facilities are required to have systems in place to guard against theft and diversion of controlled substances. It is important that all staff understand and comply with these protocols, and act in ways to minimize unauthorized access or opportunities for tampering and misuse.
  2. Early detection systems. These systems can include:
  • video monitoring of high-risk areas
  • active monitoring of pharmacy and dispensing record data
  • staff awareness of behaviors and other signs of potential diversion activity
The most effective plans involve a multifactorial approach of technology and awareness. There are programs that can be utilized to monitor the number of times medications are accessed as well as amount of medications pulled and then statistically compare one provider to another in a similar setting. 
Additional practices to consider include manual chart reviews and random evaluation of syringe contents after patient administration
These analytics-heavy approaches are limited in that they require users to separate useful data from the overwhelming amount of information generated. With these high technology solutions, patient-specific needs and complexity should be considered as the data is analyzed and reviewed.
Typically, no one method is foolproof and organizations are encouraged to implement multiple practices.  

  3. Appropriate response for staff can be summarized as "see something, say something." At the institutional level, appropriate responses include:

  • establishing a just culture in which reporting drug diversion is encouraged
  • assessing harm to patients
  • consulting with public health officials when tampering with injectable medication is suspected
  • prompt reporting to enforcement agencies 
Regulatory requirements for reporting drug diversion in health care organizations include the following:
  • Drug Enforcement Administration (DEA) — report immediately, per federal regulation (21 CFR 1301.76; 2014)5
  • state regulatory board and/or professional assistance
  • law enforcement
  • pharmacy board
  • Food and Drug Administration (FDA) Office of Criminal Investigations (OCI) for tampering cases
  • Office of Inspector General (OIG)
Drug diversion reaches beyond controlled substances.  Therefore, organizations should consider how they monitor other agents which may have potential abusive characteristics or may enhance street value of illicit substances.  
What has worked for your organization? We can only combat this problem by sharing our best practices and learning from one another? 
Robert Campbell, Pharm.D. currently serves as the Clinical Director, Standards Interpretation Group for Hospital and Ambulatory Programs at The Joint Commission. Dr. Campbell also serves as the Director of Medication Management for the Joint Commission Enterprise. Prior to joining The Joint Commission, Dr. Campbell worked in health care organizations and held leadership positions with oversight responsibilities for performance improvement, accreditation readiness, risk management, infection control, medical staff services, and inpatient and outpatient pharmacy services.