Managing the risk of drug diversion


Managing the risk of drug diversion

The case in New Hampshire of a technician stealing drugs and infecting patients with hepatitis C in the process, has placed the issue of drug diversion in the forefront of many risk managers’ minds. Here, Michelle Foster Earle, president of the OmniSure Consulting Group, offers her advice and insights on the topic.

Prescription drug abuse, which is defined as the habitual use of prescription medication to alter one’s mood, emotion, or state of consciousness, accounts for 30 percent of the overall drug problem in the US. It is becoming so pervasive, in fact, that the Centers for Disease Control and Prevention has formally labelled it an “epidemic”. As a result, the Office of Inspector General investigations of drug diversions, defined as the use of licit prescription medications for illegitimate purposes, are on the rise.

Hospital and healthcare facility risk managers have noticed. OmniSure Consulting Group is a risk management firm contracted by medical professional liability carriers to reduce risk in hospital and healthcare facilities. We started getting calls in early 2010 after an uptick in the prevalence of prescription drug abuse and diversions prompted some of our hospital clients to request training on identifying and dealing with drug abuse and diversion, which was provided at individual sites, but also promptly followed by a webinar on the topic.

More than three years later, it’s no surprise that there have been hundreds of news reports from the east coast to the west coast of prescription fraud, medical clinics that are actually ‘pill mills’ linked to large numbers of overdose deaths, or healthcare workers stealing opiates or benzodiazepines and replacing them with look-alike medications.

One highly publicized case involved a hospital technician who pleaded guilty in Exeter Hospital’s hepatitis C outbreak. He was accused of replacing painkiller syringes with syringes of saline tainted with his own blood. He is set to be sentenced on December 3, 2013, and could receive a prison term of up to 40 years. The accused had been stealing drugs for more than 10 years, “killing a lot of people” according to his plea agreement, in which he also said he had stolen pain medication in multiple hospitals in other states as well.

The issue of drug diversions is complex and can involve multiple parties, from drug-seeking patients and physician storefronts acting as pill mills, to pharmacies participating in fraud and abuse. In outpatient settings, efforts have centered on patient education, provider education, and monitoring. As many as 47 states now have formal prescription drug monitoring systems for tracking patient and provider patterns.

National associations such as the American Medical Association and the American Society of Addiction Medicine as well as state groups have released issue briefs, position statements, resources, and toolkits such as the Oregon Prescription Controlled Substances Toolkit to help address the most pressing concerns in outpatient settings.

Concerns in the inpatient setting differ. One of the most serious problems for risk management in hospitals and healthcare facilities is the theft of drugs and controlled substances by healthcare professionals in their employ who, often, are addicted themselves. The threat to patients can be severe. According to the 2010 National Drug Threat Assessment report, the most widely diverted drugs in healthcare facility settings are opioids. Overall, opioid-related deaths increased 98 percent from 2001 to 2006. It’s essential that risk managers in hospitals and healthcare facilities work to develop and implement programmes to effectively prevent and respond to drug diversions.

As a result of the Exeter Hospital hepatitis C outbreak, the New Hampshire Department of Health, in September, announced its intent to partner with the National Association of Drug Diversion Investigators (NADDI) and other advocacy groups to share recommendations for better prevention and detection of drug diversions.

This is one of the many groups that have set out to tackle this growing problem. Analyzing what went wrong in specific situations in order to learn from past experiences is always a great place to start. An extensive investigation of the Exeter Hospital’s drug diversion and disease outbreak revealed a number of gaps and opportunities for improvement in three areas: regulation and information sharing regarding allied healthcare workers, promoting prevention and early detection of drug diversions in healthcare systems, and responding to healthcare associated outbreaks in order to protect patients.

Some takeaways that can be acted on immediately by hospitals and healthcare facilities include:

1. Use all available data, including the National Provider Data Bank, to capture concerns;
2. Check references with past employers, especially across state lines;
3. Use scrutiny when hiring travelling staff;
4. Limit access to controlled substances;
5. Assess and improve processes related to preparation and use of controlled substances (for example, controlled substances should not be prepared ahead of their anticipated use);
6. Ensure real time accountability for controlled substances using techniques such as timeouts and lockdown procedures;
7. Have dedicated staff in charge of coordinating drug diversion prevention efforts;
8. Review processes and procedures related to controlled substances in each unit, assessing for gaps;
9. On an ongoing basis, educate all staff on the risk of drug diversion and what to look for;
10. Have a formal process for reporting drug diversion concerns such as questionable behavior, controlled substance discrepancies, unattended syringes, wasting of full vials, etc; and
11. Consider camera surveillance in high risk areas.

Some excellent resources are available for risk managers seeking to get started. Firms such as OmniSure can conduct onsite risk assessments and training, but risk managers who like do-it-yourself resources and proven tools, could start with the following resources.

First, visit the Minnesota Hospital Association’s patient safety page for the published results of The Controlled Substance Diversion Coalition, convened by the Minnesota Department of Health and the Minnesota Hospital Association, who came together in May 2011 in order to prevent the theft of prescription drugs by healthcare workers (

The resulting collaboration on drug diversion prevention produced a set of best practices that hospitals and healthcare facilities can use to help prevent drug diversions. Risk managers will find a road map to controlled substance diversion prevention, and a toolkit with a recommended organization structure, sample job description, reporting and response tools, worksheets, educational tools, and links to other resources.

Another great resource, found at the National Center for Biotechnology Information (NCBI) is Diversion of Drugs Within Healthcare Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention which includes research and examples from the Mayo Clinic with illustrative vignettes, summaries of the risks, general concept for drug diversion prevention, how Mayo Clinic operationalized their efforts, and ultimately a table with seventy-seven best practices to detect and prevent diversions. This is organized in the form of a checklist for drug storage, security, procurement, ordering, prescribing, preparation, dispensing, administration, inventory, recordkeeping, surveillance, investigation, education, and quality improvement.

In addition to the resources above, risk managers should check out the New Hampshire Hospital Association’s October 25, 2012 PowerPoint presentation The Mayo Clinic Experience—Preventing drug diversion: ensuring patient safety in New Hampshire (, and the many tools, tips, training materials and links at the NADDI ( 

Michelle Foster Earle, Omnisure, drug diversion, patient safety