The more you can identify, the lower your facilities risk.
Facilities handling controlled substances face the risk of diversion in various forms. Recognizing potential diversion helps to minimize these risks and maintain safety. Some vulnerabilities are unavoidable, but identifying them ensures better protection.
Common Diversion Indicators
During internal investigations, diversion may present itself as:
- Ordering/Shipping Discrepancies – Inconsistencies in delivery addresses, missing invoices, or mismatched quantities between vendor records and received goods. Receiving Discrepancies: Differences between ordered quantities and received items, or mismatches between invoices and the actual contents of packages.
- Stocking Discrepancies – Variances between received quantities and what’s physically stocked in storage.
- Transfer Discrepancies – Mismatched quantities when transferring drugs between storage locations.
- Dispensing Discrepancies – Differences between documented and actual quantities removed from storage, inconsistencies in electronic medical records (EMR), or improper balance in vials/bottles after accounting for overfill/under-fill.
- Other Indicators – Missing prescription pads, poor patient pain control, and unusual increases in waste transactions by employees.
During investigations, treat all employees equally and maintain impartiality. Drug dependence can affect even highly functional professionals, so vigilance is crucial to protect your facility and colleagues.
Reducing Diversion Risks
- Comprehensive Staff Training – Educate staff on proper drug handling, recognizing diversion signs, and reporting suspicious activities.
- Restrict Controlled Drug Access – Limit access to trained personnel familiar with standard operating procedures (SOPs) and containment devices.
- Implement Security Cameras – Use video monitoring in areas where controlled substances are stored, dispensed, or administered.
- Review Automated Dispensing System Overrides – Regularly investigate skipped or overridden transactions for controlled substances.
- Increase Cycle Count Frequency – Conduct regular cycle counts to catch discrepancies early.
- Limit On-Site Controlled Medications – Consider using external pharmacies to reduce in house controlled substances inventory.
- Timely Disposal of Expired Medications – Remove expired drugs promptly through reverse distribution to prevent diversion.
- Third-Party Audits – Engage experienced external parties to identify gaps in your record keeping and compliance.
Proactively addressing these areas can significantly lower the risk of diversion in your facility.