The risk of diversion will always exist anywhere controlled substances are received, stored, transported, used, or destroyed. Within the inpatient setting, there are numerous methods of diversion, and many diverters use multiple methods to avoid detection. Along with sophisticated diversion surveillance software (preferably including multiple data sources) and camera surveillance, staff education and training in diversion awareness are important tools for detection and prevention. When this act is suspected, in addition to running transaction data, it is helpful to obtain camera footage, staff schedules and assignments, and HR information early in the investigation.

The nature of care in certain inpatient settings may make diversion more difficult to detect. Diverters often target environments such as the ER and ICU where controlled substances are used in large quantities. Units where the staff are close-knit and tend to trust one another may also facilitate diversion.

The choice of drugs diverted typically reflect those most readily available on a particular unit. While opioids (alone or in combination with benzodiazepines and other drugs) are most commonly targeted, this may differ by site of care. In behavioral health units, for example, stimulants such as methylphenidate may be more commonly diverted. Regardless of the setting and the available medications, if there is limited staff awareness or inadequate monitoring and surveillance, potential opportunities for diversion abound.

Failure to Administer

Year after year, many of the same diversion schemes are repeated. One of the most common involves taking advantage of the situation whereby a patient has an order for an opioid but does not require it. The diverting nurse may falsely document that the patient has pain, pull and document administration of the opioid, but then keep the drug for themselves.

There are a few variations on this scheme with both range orders and orders resulting in therapeutic duplication playing a role. In one scenario, a patient has a PRN order for 1 to 2 oxycodone or an order for 0.5 to 1 mg of hydromorphone, for example, and the nurse always opts for the larger dose in order to divert a portion. A similar method is used when a patient has morphine and oxycodone ordered for the same level of pain or for severe and moderate pain, respectively. The nurse pulls both medications at the same time and diverts one of the two. In this latter instance, an excuse is often presented, explaining that the nurse is simply extra caring and sensitive to the patient’s pain.

This scheme can be difficult to detect at the outset, but over time the diverter tends to escalate to outlier status, at which point the pattern becomes evident. This diversion can be uncovered when only one nurse documents this type of administration and the patient does not require the same level of pain control when the nurse is off duty. Unfortunately, in short stay settings such as day surgery units, being the only nurse administering a particular drug is not a reliable indicator, as a nurse working the night shift may regularly have patients who have just had surgery and are in pain but are discharged shortly thereafter. A more effective way of uncovering this scheme is having the oncoming nurse conduct a thorough assessment to determine whether the patient denies having had pain or pain medication on the previous shift.

Early Removal of Medication

This method of diversion involves pulling and documenting administration more often than the medication is due. For example, if hydromorphone is ordered every 4 hours as needed for pain rated 7 to 10, the nurse may pull the medication and document administration every 3 hours during their shift. Over the course of a 12 hour shift, this allows the nurse to pull and potentially divert one additional dose. This type of diversion may be combined with other methods including pulling an additional dose under an invalid order, such as a PACU order, or obtaining a one-time order from a provider.

While some diversion software programs will detect early removal of a medication, it is often difficult to identify unless a nurse is audited. Nevertheless, a nurse using these methods eventually will flag as an outlier for usage of the drug of choice.

Overrides

Utilizing overrides to access medications for diversion occurs most often in chaotic critical care settings such as trauma units, where it is less likely to be recognized or questioned. In one case, a nurse had multiple overrides for fentanyl in the trauma setting and requested that busy and distracted providers input orders after the fact.

To prevent this type of diversion, it is imperative to strictly limit overrides and to regularly review all overrides that occur. A weekly override review is recommended. If the facility has a staffed diversion program, the diversion team may be responsible for doing this. Nursing managers may also have this responsibility, though the review is often completed by pharmacy. During the audit, it is important to ensure an order exists for each override and to recognize patterns associated with a particular nurse and drug. Also, limit what can be overridden to medications where it is truly warranted.

Unscheduled Access of Drug Storage

Staff accessing drug storage when they are not scheduled to work is a red flag for diversion. Although this method is not widespread, it is important to be aware of its possibility owing to the magnitude of product that can be diverted in this situation. There continue to be cases where staff enter a unit that is closed on the weekends or overnight to divert drugs. In some cases, a nurse on medical leave has entered the facility to carry out a diversion scheme. The diversion is usually accomplished by cancelled or null transactions that facilitate tampering.

Surveillance software that incorporates data from staffing schedules can be helpful in identifying this type of scheme, as can programs that flag null or cancelled transaction outliers. As with such programs, this type of activity may not be detected for some time and is often found only when there is overt evidence of tampering and transaction reports are then reviewed to identify a potential culprit.

Tampering

Unfortunately tampering remains a common method of diversion and is undoubtedly one of the most dangerous because of the resultant risk of bloodborne pathogen transmission or administration of an unsafe substance to a patient. Tampering consists of altering the contents of a syringe, vial, or other administration container by replacing all or part of the contents with another substance, such as tap water.

It is important to educate staff on signs of tampering and what steps to take when tampering is suspected. The best strategy to detect tampering is to train staff is to look at product integrity during routine transactions such as during blind counts, before administration, and during stocking and inventories.

Creating Discrepancies

Creating a discrepancy by blatantly removing medication from a storage unit is a feasible method of diversion in any facility where discrepancies are not taken seriously. There are instances in which staff use discrepancies to supplement other methods of diversion.

To prevent this type of diversion, discrepancies should be resolved at the conclusion of a shift and discrepancy resolution reasons should be monitored. This helps ensure staff are not simply clearing discrepancies without determining what actually occurred. Keep in mind that accreditors and state boards of pharmacy also require that discrepancies are properly addressed.

Removal for a Discharged Patient

In units where there is a rapid turnover of patients, such as the ED, outpatient procedural units, and short stay units, pulling medication for a patient who has been discharged is a relatively easy method of diversion. Diverters using this method are often flagged as outliers, so it is important to be cognizant of discharge times when reviewing transactions. If the EHR does not show the discharge times clearly, the nurse’s notes or flow sheets may provide useful information about when the patient left the premises.

In one case, a nurse routinely pulled oral opioids at or near the time of discharge. As the scheme progressed the nurse became less cautious and their notes in several cases revealed that they had escorted the patient to the exit 10 minutes before the medication was pulled. To prevent this, it is imperative to limit the time the patient profile remains active in the drug dispensing system post-discharge.

Diversion from Waste

All facilities should have a controlled substance waste disposal system in place, but these systems alone do not eliminate the risk of diversion from waste. If the systems are not properly introduced and maintained, staff may toss intact syringes or vials into sharps containers or waste into sharps containers, trash cans, and other locations from which waste might be diverted. To prevent this, controlled substance waste receptacles should be placed in locations that are convenient for staff to use. Staff must be educated on how to properly use the receptacles, and the receptacles must be emptied regularly. Include an inspection of waste receptacles on the regular rounds of clinical units to be sure that they are being used properly and to determine whether intact syringes or vials are present in sharps containers.

There is an increased risk for diversion from waste when complete doses are wasted by staff. Thus, regular monitoring for a pattern of wasting complete doses should be a standard part of diversion auditing of outliers. In one instance, a nurse used this method multiple times per shift for a month, when her outlier status ultimately led to her being caught.

Diversion from waste also occurs when wasting is delayed or is improperly witnessed. Too often, a nurse purporting to witness waste simply completes the verification, trusting their colleague to be honest. Because nurses perceive wasting as a low priority compared to medication administration, education on the responsibility of properly wasting and witnessing waste needs to be repeated regularly. Education should underscore the witness’s obligation to first verify that the label and the quantity of the wasted medication is what it is purported to be, and then to visualize the actual destruction of the medication. Unfortunately even with a diligent witness, diversion may occur. In a recent case, a nurse admitted pulling a bubble of air into a syringe so that air and some medication were expelled in front of the witness while the remaining medication was diverted.

Pairing/Substitution

An increasingly popular diversion method is pairing/substitution, whereby the nurse pulls a non-opioid analgesic using a null or cancelled transaction and pulls an oral opioid at the same time. The nurse then administers the acetaminophen or ibuprofen, while diverting the opioid. A pattern of null or cancelled transactions for a non-opioid analgesic at the time an oral opioid is pulled should be regarded as suspicious. Keep in mind that some pairing transactions may be innocent, such as when a patient has acetaminophen scheduled around the clock and also receives an opioid as needed; a night nurse might choose to pair medications to avoid unnecessarily waking or disturbing the patient. This scheme becomes apparent when there is no explanation for the non-opioid analgesic transaction, such as when acetaminophen is ordered for fever but no fever is recorded or when it is ordered for mild pain and pulled at the same time as an opioid used for moderate or severe pain.

Conclusion

Diversion in inpatient units is an arms race between the diverters focused on developing schemes to provide undetected access to medications and the staff tasked with detecting and preventing diversion. It is important to acknowledge that while it is impossible to eliminate diversion entirely, it nevertheless is essential that hospitals remain cognizant of the latest methods of diversion and develop effective ways to detect and prevent them.

Kim New, JD, BSN, RN is a specialist in controlled substance security and DEA compliance. She has served as a consultant to healthcare facilities across the country, helping set up and expand drug diversion programs to improve patient safety. Kim currently works remotely as a diversion program consultant with a large US health system.