Joint Commission issues Quick Safety advisory on drug diversion and impaired health care workers

Drug diversion patterns, trends and safety actions identified Tuesday, April 16 2019

Katie Looze Bronk
Corporate Communications
(OAKBROOK TERRACE, Illinois, April 16, 2019) – An estimated 10 percent of health care workers abuse drugs, according to the U.S. Substance Abuse and Mental Health Services Administration and the American Nurses Association.
Availability and access to medications in health care organizations can make it difficult to detect and prevent drug diversion—a serious potential threat to patient safety. Patient risk from drug diversion includes inadequate pain relief and exposure to infectious diseases from contaminated needles and drugs, as well as potentially unsafe care due to a health care worker’s impaired performance.
A new advisory from The Joint Commission, Quick Safety, Issue 48: “Drug diversion and impaired health care workers,” encourages health care organizations to establish a comprehensive controlled substances diversion prevention program to help detect and prevent drug diversion.
The advisory also reviews patterns and trends that indicate potential diversion such as when controlled substances are removed with no doctor’s order, product containers are compromised, verbal orders for controlled substances are created but not verified by the prescriber, prescription pads are forged, and much more.
According to the alert, the three essential components health care organizations need to consider when dealing with drug diversion are: prevention, detection and response. Safety actions in each area include:
  • Prevention: Health care facilities are required to have systems to guard against theft and diversion of controlled substances. 
  • Detection: Health care facilities must initiate systems to facilitate early detection such as video monitoring of high-risk areas, active monitoring of pharmacy and dispensing record data, as well as staff who are aware of and alert to common behaviors and other signs of potential diversion activity.
  • Response: Appropriate response for staff should be “see something, say something.” At the institutional level, appropriate responses include establishing a just culture in which reporting drug diversion is encouraged.
The Quick Safety is available on The Joint Commission website. It may be reproduced if credited to The Joint Commission. 

About The Joint Commission
Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 21,000 health care organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. Learn more about The Joint Commission at