Although drug diversion may be considered a rare event, investigations reveal that the practice could be going undetected in facilities that do not have a proactive prevention program, warns Kimberly New, JD, BSN, RN, executive director of the International Health Facility Diversion Association.

“Having a formal program is essential. If you are treating this as a one-off, you are going to be inconsistent and have an incomplete response,” she said recently in Minneapolis at the annual conference of the Association for Professionals in Infection Control and Epidemiology.

In the most basic terms, the program should increase transparency and develop a culture of accountability. “If you are not open within the organization about drug diversion, then people are not going to believe it’s a risk,” she said. “Make sure you have a good auditing surveillance program in place. Risk rounding is essential to prevention.”

Employee health professionals looking to establish or improve a drug diversion program at their facilities may want to consider some of the measures taken by JoAnn Shea, ARNP, MS, COHN-S, director of employee health and wellness at Tampa General Hospital.

Shea and colleagues are following Guidelines on Preventing Diversion of Controlled Substances, issued last year by the American Society of Health-System Pharmacists (ASHP).1

The ASHP recommends forming a drug diversion committee that should include members from employee health, pharmacy, nursing, risk management, security, and other departments. Another key step is hiring a diversion specialist who can dedicate his or her time to detecting and preventing drug theft and tampering.

All of the Tampa General specialist’s time is devoted to identifying diversion, Shea says.

The ASHP recommends that the diversion officer should have a license and a college degree in pharmacy or nursing, with at least five years of healthcare experience. At Tampa General, a pharmacy nurse specialist has been hired as the drug diversion point person.

“We actually created that position for her,” says Shea, who co-chairs the hospital’s Controlled Substance Diversion Prevention Committee. “She reports to me and to the pharmacy director. It’s kind of a ‘dotted-line’ relationship.”

Duties include education, diversion identification, audits, and conducting a gap analysis based on ASHP best practices. The diversion committee meets quarterly and is currently conducting a gap analysis of drug use and controls throughout the facility. The hospital IT team developed software that can show graphs and detailed drug use by unit.

“It is an internal database that we can look at to review diversion issues,” Shea says.

The diversion specialist and members of the team also are creating a controlled substance workflow checklist to be used in unit audits. In reviewing drug use practices, Shea says she is seeing medication overrides granted too routinely.

“That is not really a best practice, but once it is accepted it becomes the norm,” she says. “We have had some diversion issues with discrepancies. One of the nurses will go to the charge nurse and say, ‘I miscounted — the count’s off.’ And instead of doing a look-back [investigation], the nurse signs off.”

The committee decided to ramp up education and training on diversion and drug-wasting, which prior to that had been a 30-minute program for new hires.

“We realized there is a lot of training and education involved,” she says. “We needed education on diversion, discrepancies, and waste.”

During an audit, the diversion specialist may pull charts and documentation to see if, for example, any leftover drug was wasted within 30 minutes of administration.

“Did they administer the drug within 30 minutes or an hour of signing it out?” Shea adds. “Those are the kinds of things we are looking at.”

The audit checklist is a work in progress, with Shea and colleagues still identifying components to be assessed. Those may include establishing some benchmark for the number of discrepancies a given unit should have.

“Why does this unit have 100 discrepancies and every other one has 10?” she says. “We are still building that part of the program. We based our gap analysis on what the ASHP recommended — their [guidelines] are very well put together.”

Given the diverse challenges of a large hospital system and a single diversion specialist, interventions will have to be prioritized.

“We can’t do everything at once with one person,” Shea says. “We have to look at our inpatient pharmacy and our flow of drugs between our ambulatory facilities and inpatients. We have a freestanding ER and a surgery center. We want to make sure the chain of custody is being followed when we are moving controlled substances to the hospital.”

Risk Points

The ASHP warns that there are multiple risk points for drug diversion as controlled substances move through healthcare systems. These include the following at various phases:

  • procurement;
  • preparation and dispensing;
  • prescribing;
  • administration;
  • waste and removal. 


1. Brummond PW, David F. Chen DF, Churchill WW, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. American Journal of Health-System Pharmacy 2017, ajhp160919; DOI: