Diversion: A Quiet Threat in the Healthcare Setting

By Carol McCammon, MD, FACEP

Carol McCammonHave you ever felt a brief sense of uneasiness about certain situations in patient care? Maybe you have vaguely noticed that your patients seem to have a greater degree of perceived pain when Nurse Philips is on duty, or that he/she seems excessively enthusiastic at the prospect of extra shifts, or that he/she volunteers to manage his/her coworker’s assignments when the department is especially busy, particularly when there seems to be frequent medication needs.  Maybe it struck you as odd for a brief moment in the course of the shift, but the pressures of the moment may have made you move on to the next critical patient. Enter the quiet threat; attend to your instincts.

The Uniform Controlled Substances Act of 1994 Section 309 defines “diversion” as the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use.  As emergency physicians, we are all too aware of the public health crisis of prescription medication misuse in the general public, and we dread the resultant difficult patient encounters that must be managed safely and effectively.  Yet the less obvious sources of diversion at the point of care remain rather elusive, and when they unfold in your department, they cause tremendous distress to the staff, reveal undetermined patient safety concerns and definitively impact the lives of those affected.  Of the few published studies of diversion involving healthcare workers, nurses are identified as the most frequent sources, with physicians, medical assistants and pharmacists to a much lesser degree6.  Awareness and staff education, detection methods, policy development and enforcement with leadership support will enhance recognition to effectively confront diversion and place prevention methods in place.

Unfortunately, there is no data that accurately reflects the degree to which this problem exists1,6, but the potential harm to the diverter, the patients, the coworkers and the healthcare institution is immense, and multiple cases have been reported in the media and heard in the courts that reflect horrifying outcomes. Take for example the case of a 26 year-old surgical technician, who stole fentanyl syringes off the cart when no one was looking2.  At first she took only unused needles, and as time passed and her addiction progressed, she swapped out needles she had used to inject herself, ultimately exposing nearly 6,000 people to her Hepatitis C virus. Is this an extreme case? Possibly, yet there are other well-documented similar stories.  Another case in the Virginia Court of Appeals describes the case of a hospital nurse who “1) repeatedly failed to document administration of wastage of multiple controlled substances including fentanyl, a Schedule II narcotic; 2) overrode protocol by administering medications to patients who were not yet scheduled to receive them; and 3) had the highest rate of discrepancies in withdrawals, administration, and wastage of narcotics. The Board also found that appellant tested positive for fentanyl and norfentanyl, neither of which she had a prescription for, on a drug test administered while appellant was on duty.3” Sadly, these cases only indicate a small proportion of the potential harm that continues to progress unseen at the hands of diverters yet unrecognized.

The most frequent reasons healthcare workers, from nurses to physicians and all in between, cite for diversion are related to personal health problems for which they are self-medicating, obtaining drug for an ailing or addicted family member or friend, personal substance abuse and addiction, and less commonly sales of drugs for profit.1 The most commonly diverted drugs are meperidine, fentanyl, morphine, oxycodone, and hydrocodone. Other less common substances implicated in diversion cases include high value pharmaceuticals, such as antiretroviral drugs, performance-enhancing drugs (steroids and erythropoeitin) and non-opioid psychotropic medications.1 Situations of diversion from the emergency department perspective focus primarily upon opioids.

The checks and balances in effect for outpatient prescription management are not practical in the inpatient setting, thus opportunity exists for a determined individual to quietly work around a more vulnerable system in a bustling environment where eyes cannot be perpetually attentive.  Among the most common opportunities for individuals to divert medications from in-hospital order origination to patient administration include:

  • The substitution of the diverted medication for another patient. For example, an order is placed for Percocet tablets, the nurse accesses the automated dispensing cabinet, pockets the pills, and gives the patient the aspirin she is carrying instead.
  • One could also inaccurately chart medication administration at the point of care, leading to a situation in which the chart reconciles with the automated dispensing cabinet record, even though the patient never received the medication.     
  • Falsification of orders (especially verbal orders) may allow a worker to obtain more product than necessary for a patient, and take the occasion to lift the excess. 
  • Similarly, at the automated cabinet level, one could remove more medication than ordered while documenting the removal of only the ordered amount. 
  • At the bedside, home medication reconciliation provides an opportunity for a healthcare worker to pilfer the patient’s own medication right from the pill bottles.
  • Leftover medications in sharps containers have proven a potentially deadly source for desperate individuals, and can promote the spread of life-threatening infectious disease by contaminated sharps injuries.
  • Improper disposal of medication waste may allow one to document a medication was disposed of properly while in reality the excess was kept for personal use.

All of these situations have the obvious potential to harm the patient, either through omission of legitimate pain control, potential exposure to infectious disease, sepsis from injection of unsterile drug substitute (e.g. tap water6), potential exposure to an undetermined substance with unclear and unanticipated clinical effects, anaphylaxis, or from substandard care provided by a distracted or impaired caregiver. The diverting health care worker has placed himself in harm’s way as well, with the real potential for death from overdose, the disability of untreated drug addiction, the exposure to blood borne pathogens, and transmission of pathogen to their patients. Further, as unknowing, newly infected patients from blood borne pathogen exposure continue in their routine lives, they then have the potential to exponentially infect more and more individuals leading to a very real and substantial public health problem. Not only are there personal health implications for diverting workers, but also their professional lives hang in the balance with the potential for revocation of license and privilege, professional board sanctions, criminal prosecution for theft and/or fraud, and civil malpractice litigation. 

As multiple team members share responsibility for the treatment of all ED patients and for the maintenance and housekeeping of the treatment areas, consider the risks to other workers in the department as a careless rummage through a sharps container leaves exposed contaminated sharps in unexpected places.  Manipulation of the drug cabinet and of colleagues is a skill central to successful drug diversion. Sharing a password with a diverting colleague who claims she is “locked out” and needs an urgent medicine for her patient can result in fictitious blame to the innocent colleague. Similarly, deviating from policy and acknowledging medication waste that wasn’t directly witnessed places the innocent at risk of disciplinary action while enabling the diversion activity.  

At the facility level, risk of civil liability exists if harm to a patient is related to a failure to prevent, recognize or address signs of an impaired employee. Although there are variations in state law, failure to report diversion or theft of controlled substances is a federal offense8. Investigations prompted by suspicions of diversion are costly and time consuming. Well-organized, fair and thorough policies and processes help with effective risk management, and ensure the obligation of duty is met to the health care worker and all patients and parties that could have been affected.  The institution also has mandatory obligations to report identified cases of diversion and once reported are available to the public. Exposure and scrutiny through the media can have a profound impact on the hospital, the individual, and the morale of coworkers and may result in patients self-triaging away from the institution with the financial and reputational repercussions obvious. 

Identifying an at-risk worker poses challenges. The differentiation of signs of impairment can overlap with signs of stress, and care must be taken to carefully evaluate each situation, with the support of the department management and the hospital leadership.  Records and reports generated from automated dispensing systems can be very helpful in calling attention to irregularities and to employees that access drugs at a higher frequency than peers, yet this information cannot stand alone to prove diversion is the reason for the finding.  Potential provider behaviors that may raise concern for the possibility of diversion or impairment include:

Patient Care Factors
- Documentation inconsistencies or inaccuracies
- Inconsistent performance quality
- Offers to medicate other nurse’s patients frequently
- Provider accesses large doses of medications when the correct dose is available, and documents wasting of the excess
- Provider seeks to care for specific types of patients
- Describes in detail the specific controlled substance needs of his/her patients
- Patients of the provider disproportionately complain of unrelieved pain after medication
- Provider disappears into the restroom after accessing medications7

Behavioral Factors
- Provider avoids social interaction with staff, often breaks alone
- Provider takes long breaks or disappears during shift with no explanation
- Provider volunteers frequently for extra shifts
- Provider shows up on days off work
- Provider frequently spills or wastes controlled (and sometimes other) substances
- Provider may have an unstable personal life
- Impulsivity
- Implausible explanations for behavior in question
- Excessive drowsiness or confusion

The presence of any one of these factors cannot stand alone to verify diversion, and they must be considered carefully in the context of the situation.  Other behavioral factors such as significant behavioral changes, negative trends in work productivity, and unexplained & unpredictable absences can be general indicators as well. 

Prevention and Detection Strategies:

  • Supporting evidence can be gathered from software reports that control automated medicine cabinets (eg Omnicell or Pyxis.)  It is in the best interest of the department and the hospital to be certain these reports are run and monitored regularly and frequently in conjunction with the hospital pharmacy department.
  • Raise awareness of the issue as part of new employee orientation for all workers, not simply limited to those with access to controlled substances.
  • Periodically revisit the issue with policy and procedural reviews in an effort to remind all employees of the existing safeguards to prevent harm to patients, support prevention and promote treatment of addiction.
  • Make the pathways known within the organization for all employees to access resources and contact the appropriate leadership in the event of suspected diversion or impairment.
  • Mayo Clinic proposes a web-based teaching module that they may utilize as an annual requirement for continued employment1.
  • Organized programs aimed to prevent diversion and promote early detection are preferential to reactionary efforts.
  • Automated Drug Dispensing Cabinets are very helpful, but are not foolproof:
       o Tracking software must be activated and generated data must be reviewed to detect unusual patterns.
       o Secure waste retrieval systems can be installed within the automated cabinet to allow for random quantitative drug evaluation to ensure quantities
          match documentation.

A uniform approach with active surveillance throughout the entire hospital/health system is desirable. Some facilities have created a single position supported by a team to coordinate diversion prevention efforts hospital/system-wide. The lead person must have understanding of both institutional policy and the controlled substance supply chain from the pharmaceutical company to the pharmacy department to the distribution channels throughout the hospital, and a keen awareness of vulnerabilities in the system. This committee is also responsible for evaluation of reports of diversion to bolster identified vulnerabilities1.

  • Access to the defined process at all hours and by all employees to activate an investigation or to prompt immediate administrative response to a suspected impaired employee allows a timely approach to immediate removal of any impaired employee from patient care activities and a mechanism to begin a systematic investigation which must be defined in institutional policy.
  • Investigations can be closed when enough information has been obtained to confirm or negate that diversion has occurred.
  • Institutional leaders hold the responsibility of intervening in the case of suspected diversion, securing the individual(s) and addressing employment status, and reporting diversion to the appropriate Board/Department of Health and law enforcement authorities.
  • Diversion can be a symptom of addiction, and the potential to effectively treat an individual with intensive therapy and rehabilitation may salvage a life and a career. Compassionate and direct attention with effective processes for early identification and intervention are absolute necessities in the risk management of diversion and impairment.
  1. Berge KH, Dillon KR, et al. Diversion of drugs within healthcare facilities, a multiple-victim crime: patterns of diversion, scope, consequences, detection and prevention. Mayo Clinic Proceedings. Vol 87: Issue 7; July 2012.
  2. Addicted docs put patients in peril. Random drug screening urged for healthcare workers. http://www.nbcnews.com/id/37396390/#.UoDpmZTwJ38
    Accessed 11/11/2013.
  3. Prior v. Virginia Board of Nursing; Court of Appeals of Virginia, Richmond.
    Record No. 0160-13-2. October 15, 2013.
  4. Healthcare workers could face random drug tests in NH.
    http://www.fiercehealthcare.com/story/healthcare-workers-could-face-random-drug-tests-nh/2013-02-27
    Accessed 11/12/2013.
  5. Kentucky Board of Nursing: Case Studies.
    http://www.kbn.ky.gov/conprotect/casestudies.htm
  6. Accessed 11/17/2013.
  7. Inciardi JA, et al.  The diversion of prescription drugs by healthcare workers in Cincinnati, Ohio. Substance Use & Misuse. 41:255-264; 2006.
  8. Smith LL. The Role of the Nurse Manager.
    https://www.ncsbn.org/chem_dep_handbook_ch4.pdf
  9. Accessed 11/10/2013 and 11/17/2013.
  10. Strengthening strategies to deter drug diversion. Pharmacy Practice News.
    December 2010. Vol. 37
    http://pharmacypracticenews.com/ViewArticle.aspx?d_id=52&a_id=16389
  11. Accessed 11/13/2013.

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