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Conducting an Internal Assessment of your Drug Diversion Surveillance Program

How effective is your Drug Diversion Surveillance Program?

Controlled substances are abundantly available and accessible in hospitals and health care organizations. The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) and the American Nurses Association (ANA) suggest that approximately 10% of health care workers abuse drugs[1]. How many incidences of Drug Diversion have you identified within your organization? It can be challenging to identify and prevent diversion without a comprehensive surveillance program in place. 

The Joint Commission has outlined top priority elements to a successful Diversion Surveillance Program[1]:

  1. Leadership Oversight
  2. Legal and Regulatory Requirements
  3. Monitoring and Surveillance
  4. Automation and Technology
  5. Pharmacy Controls

It is important to focus on these areas of concentration when evaluating your drug diversion surveillance thoroughly. Drug Diversion is a threat to both patient safety and employee safety. Understanding the key elements to identification and prevention of diversion is the first step in the assessment process. 

Leadership Oversight

Diversion of controlled substances has been observed across all levels and disciplines within an organization. Education is crucial for both leaders and employees to aid in identifying anomalous behavior amongst their employees and peers. The culture of support and empowerment to recognize and report must come from the top down of the organization as well as within each discipline. Successful Drug Diversion Surveillance Programs are established through interdisciplinary collaboration. The formation of an interdisciplinary Diversion Committee and Diversion Incident Response Team are necessary elements to thorough oversight. Consistent prioritization and active involvement from leadership will combat complacency. 

Legal and Regulatory Requirements

There are several regulatory requirements for reporting drug diversion within an organization. A standardized approach to investigation and reporting are essential components to a fair and complete Drug Diversion Surveillance Program. The DEA and other regulatory bodies generally expect facilities to adhere to industry best practices to ensure safety and medication security, regardless of whether specific requirements are published. Regulatory requirements for reporting suspected diversion or confirmed loss may include, but are not limited to, the following[2]:

  • Drug Enforcement Administration (DEA) per 21 CFR 1201.76;2014
  • State regulatory board and/or professional assistance 
  • State Board of Pharmacy 
  • Local law enforcement 

Monitoring and Surveillance

The most successful Drug Diversion Surveillance Programs involve a dual approach of technology and awareness. Data is vitally important in identifying practice patterns and trends. When combined with awareness and a “see something, say something” environment, an organization can effectively analyze the data while considering the complexities of practice. A close-looped audit of all practice areas and identification of practice patterns can be extremely labor-intensive and challenging to maintain. The incorporation of automation and technology can improve thoroughness and redeploy resources back to patient care. 

Automation and Technology

While there are several solutions on the market that support Drug Diversion Surveillance, not all are created equal. Identification of an event and follow-up must occur as soon as possible to ensure safety and accountability. Automation and technology should also support workflows and communication between disciplines to encourage collaboration. To effectively evaluate different technologies, it is important to understand the difference between supervised and unsupervised machine learning. Supervised machine learning means that the data is “labeled” and metrics are designated a definition of “normal.” Contrary, unsupervised machine learning finds and evaluates patterns within data in real-time. Unsupervised machine learning is much more complex and identifies groupings within data, as well as outliers to that “normalized” grouping.  The “normalized group” can evolve over time as the data evolves. Identifying hidden patterns within datasets and the presentation of real-time data help identify risky behavior within an organization. Closed-loop audits and behavioral analytics support leadership initiatives, oversight, and response. 

Pharmacy Controls

Pharmacy is ultimately responsible for medication security within an organization. Pharmacy personnel also have significant access to controlled substances. Diversion can occur during procurement, preparation, and/or dispensing of controlled substances. Oversight of each point in the process can minimize risk and opportunity for diversion. Implementing safeguards and routine auditing will help improve oversight and security from the manufacturer all the way to the patient.   

With an understanding of the key elements to a successful Drug Diversion Surveillance Program, organizations can adequately assess their operations and implement change effectively. 


This brings us back to the question: How effective is your Drug Diversion Program?

Click here to download our Drug Diversion Program Internal Assessment to measure your own pharmacy’s effectiveness.