With drug diversion by healthcare workers increasing, employee health professionals should be wary of incidents of medication tampering and substitution, says Kimberly New, JD, BSN, RN, founder of Diversion Specialists.

“We are seeing a very substantial number of cases of people tampering with injectables,” she says. “We hear from facilities all the time that they have had a case either recently or in the past of someone who was caught replacing an opioid with saline or something like that.”

Beginning well before the ongoing national opioid epidemic, drug diversion by addicted healthcare workers has caused repeated outbreaks, exposing thousands of patients to bloodborne pathogens. These incidents have raised awareness, meaning the increase could in part reflect better case identification and surveillance. Still, some healthcare facilities do not seem to have diversion on their radar.

“I find it very concerning because many times, I think that facilities simply aren’t aware of the risk of bloodborne pathogen transmission in these types of cases,” New says. “So, they don’t take precautions that could help protect patients and at least limit the extent of an outbreak.”

As reported recently by the CDC,1 the latest outbreak involves an ED nurse in Washington state who admitted to stealing opioids and other drugs intended for patients. The nurse has been linked to hepatitis C virus (HCV) infections in at least 12 patients who sought care in the ED, the CDC reports. The investigation is continuing, with some 90 additional patients being contacted to recommend testing for bloodborne pathogens. The nurse apparently was originally infected by diverting drugs from a patient with HCV, then infected other patients through contaminated syringes, needles, or vials, the CDC noted.

New was not involved in the investigation, but she commented generally about such cases.

“We see individuals who go into the PIXIS [machine] take out these syringes, inject themselves, fill them up with something else, and then put them back,” she says. “In that way, she could have transmitted bloodborne pathogens because there are tampered syringes filled with something other than the opioid now tinged with her blood.”

In other cases, healthcare workers draw up the contents of a vial, inject themselves with half of it, and then fill the syringe back up with something like injectable Benadryl, she explains.

“It makes the patient feel like they have gotten something by having a sedation effect,” New says. “They are diluting what the patients is given, but they are using the same needle. People who are doing this are desperate. They are not paying attention to what they have been taught as a healthcare provider in terms of safe injection practices.”

The recently reported outbreak certainly shows it is an ongoing problem.

“Healthcare facilities really need to take any kind of drug diversion seriously, and always — in every single case — consider the risk that there has been tampering and substitution,” she says. “It potentially can expose healthcare facilities to a fair amount of liability. It is something that every single facility needs to consider at the beginning, when they realize that they have had injectable diversion.”

This problem historically has been driven underground by hospitals concerned about liability following patient notifications. However, that is changing as hospitals realize admitting errors can minimize liability, she says.

“[Drug diversion] should be approached in a similar fashion,” New says. “Instead of being overly concerned about liability, really look at the risks to patient harm at the front end and err on the side of caution.”

The hospital in Washington apparently had some drug diversion oversight and saw that the nurse was taking out more medications that her colleagues.

“In general, a lot of facilities still do not have a formal drug diversion program where they have someone who is ensuring there is ongoing effective auditing and making sure that anomalies in drug cabinet transactions are followed up,” New says. “That type of auditing and work is very labor-intensive. In most facilities, it really does warrant having a full-time person in charge of that. I think the cases like this are making that more common.”


  1. Njuguna HN, Stinson D, Montgomery P, et al. Hepatitis C Virus Potentially Transmitted by Opioid Drug Diversion from a Nurse — Washington, August 2017–March 2018. MMWR 2019;68(16):374-376.