Skip Navigation

Kit Check Hospital Pharmacy Operations Report Reveals Over a Third of Hospital Pharmacy Professionals Are Aware of at Least One Colleague Who Has Stolen Controlled Substances

 Report shows diversion, shortages, and patient safety among top priorities for pharmacy personnel

WASHINGTON (APRIL 21) – Kit Check, the leader in automated and intelligent medication management solutions for hospitals, today announced the findings of its 4th annual Hospital Pharmacy Operations Report, which surveyed 237 top hospital pharmacy leadership professionals in the fourth quarter of 2019. The report aimed to capture sentiment, expectations and circumstances that collectively reflect the state of pharmacy operations in more than 1,000 U.S. hospitals and was conducted prior to the COVID-19 pandemic. The report sheds light on the importance of unit-level visibility throughout the pharmacy supply chain, which is even more critical now amidst the current pandemic, as hospitals and health systems are pushed to their limits and forced to navigate unprecedented challenges associated with drug shortages and allocation of resources.

Kit Check’s report revealed that detecting and preventing drug diversion and discrepancies remains a top priority for hospital personnel, along with patient safety, drug shortages and recalls. In fact, more than 53 percent of survey respondents reported having a diversion event within the last year, and 37 percent were aware of at least one colleague who has diverted controlled substances. According to respondents familiar with diversion events in their organizations, 47 percent stated that drugs were diverted from waste or leftover medications and about 27 percent reported diversion directly from patients. In the midst of a widespread national opioid epidemic, stewardship across the industry is needed to mitigate the crisis and protect frontline medical professionals and the patients they care for. Despite the growing problem, an astonishing 42 percent of survey respondents still do not have a diversion committee in place to deter the diversion of controlled substances

The results of the report showed that pharmacy personnel are highly focused on patient safety and have an interest in drug diversion prevention. Nearly 80 percent of respondents reported patient safety as the most important factor when it comes to securing budgets for new technology implementations within the pharmacy. Forward-thinking pharmacies are already utilizing available technology to make their workplaces safer for patients and to streamline inventory management processes. This includes controlled substance tracking software that increases medication intelligence within the pharmacy.  

Other findings from the report include:

  • Drug shortages persist in hospital pharmacies: For the second year in a row, medication shortages ranked as the top challenge facing pharmacy personnel. About 60 percent of pharmacy staff reported dealing with up to 20 medication shortages at a time. More than 72 percent of respondents reported spending up to 15 staff hours to reconcile each medication shortage.
  • Recalls also affect pharmacy personnel: 85 percent of those surveyed reported dealing with at least one drug recall every year. About 50 percent of respondents dealt with up to nine recalls every year, with the majority spending up to five hours handling each recall.

“The findings of the 2019 Kit Check Hospital Pharmacy Operations Report survey clearly show that the goals of hospital pharmacy staff are positive and that diversion prevention is top of mind—with good reason,” said Kit Check co-founder and CEO Kevin MacDonald. “With 37 percent of respondents reporting in-house opioid diversion, it is clear that a gap exists between implementing organizational change and efficiency that directly impacts patient care and safety, as well as provider and staff wellbeing.”

In a separate recent analysis conducted by Kit Check using data from its Bluesight™ for Controlled Substances™ software, nearly 9 million cases, described as a dispense and administration of a controlled substance with corresponding medication waste or medication return, were reviewed. Of these cases, 12 percent contained a variance, described as a controlled substance dispense followed by an unexpected pattern of administration and waste. Of those cases, 19 percent contained a variance involving an anesthesiologist and 11 percent involving a registered nurse. The most commonly diverted controlled substances are fentanyl, midazolam, morphine and hydromorphone, with 422 investigations opened in 40 hospital systems since April 2019. See Kit Check’s Diversion Quarterly for more information.

“Medication intelligence and unit-level visibility are critical components to manage drug shortages amidst the COVID-19 pandemic,” said Kit Check co-founder Tim Kress-Spatz. “Pharmacy personnel are the key stewards of safe medication use throughout the hospital setting. We hear these pharmacy personnel loud and clear, and look forward to providing aid to the opioid crisis and medication shortages with our expertise and ‘Best in KLAS’ products.”

The full report can be viewed here.

About Kit Check™

Kit Check is the leading provider of automated medication tracking and diversion detection solutions for hospital pharmacies in the U.S., bringing visibility, simplicity, and predictability to the complex world of medication supply management. Our groundbreaking medication intelligence platforms provide item level visibility, workflow simplicity and actionable analytics, empowering stakeholders to deliver the right medicine to the right patient at the right time, every time. To date, our more than 500 U.S. and Canadian hospital partners have tracked more than 100 million medications using Kit Check’s RFID product. Bluesight™ for Controlled Substances software is currently in use in more than 100 hospitals including full health system implementations, with nearly 9 million cases tracked, and was ranked #1 in the Drug Diversion Monitoring category in the 2020 Best in KLAS report. More information about Kit Check and our software solutions can be found at


Jill Gross