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Kit Check’s Diversion Trends Report Reveals 8% of Controlled Substance Transactions in Hospitals Had Discrepancies Indicative of Potential Drug Diversion

Kit Check, the industry leader in Medication Intelligence™ solutions for hospitals, today announced the findings of its first-ever Diversion Trends Report, which analyzed controlled substance medication transactions in more than 230 hospitals using Bluesight for Controlled Substances between September 2018 and December 2021. The report aims to offer insight into the types of drug diversions and investigations that may be occurring in hospitals amid the ongoing U.S. opioid epidemic. It offers clarity into variances, indications that a discrepancy was identified between a medication order and the administration of the medication. These variances represent a potential instance of diversion, which can often require further review.

The Diversion Trends Report revealed that in over 50 million transactions, about 8% – or four million – were flagged with a potential variance. However, the report shows that there has been a gradual decrease in the percentage of controlled substance medication transactions that were flagged with a potential variance. In Q1 2020, 12% of all cases included a discrepancy between the medication dispensed and the medication administered. By Q4 2021, this percentage decreased to 8%. Among the cases with variances, approximately 84% involved RNs, which can be attributed to staff in this role handling a majority of transactions. Cases involving anesthesiologists and nurse anesthetists followed at a distant 2nd and 3rd.

Of all the transactions tracked, hospitals have been able to use Bluesight for Controlled Substances to identify 131 confirmed cases of diversion, which can be defined as unaccountable loss, theft, tampering, or transfer of a drug from its intended purpose to another person for illicit use. Identifying instances of diversion can help those with substance use disorders get the help they need and ensure that patients are receiving the treatment and medication that has been prescribed to them. When investigations are opened based on specific analytics data flagged by Bluesight for Controlled Substances they are 4x more likely to lead to a confirmed case of diversion compared to a routine investigation.

Perhaps unsurprisingly, fentanyl has accounted for the largest share of discrepant medication transactions. In fact, since September 2018, fentanyl accounted for 22% of all cases with variances. This is aligned with provisional data from the CDC, which found that nearly 108,000 people died of drug overdoses in 2021, and about two-thirds of those deaths involved fentanyl or another synthetic opioid. Other interesting findings from the Diversion Trends Report include:

  • In Q1 2020, morphine was involved in 12% of all discrepant controlled substance medication transactions. By Q4 2021, its share was reduced to 8%.
  • There has been a sizeable increase in the average number of days required to resolve an investigation. At the start of 2021, the average investigation was closed in 23 days. By the end of 2022, the average number of days increased to 34, representing the highest quarterly average observed to date.
  • The average number of investigations per hospital has more than doubled since Q1 2020.
  • Having a system in place where people feel comfortable reporting possible cases of diversion is crucial – one third of all investigations based on colleague and patient reports have led to a confirmed case of diversion.

“The ability to monitor controlled substance transactions for instances of variance plays a huge role in hospitals’ ability to detect drug diversion,” said Kevin MacDonald, CEO and co-founder of Kit Check. “Kit Check’s mission is to ensure that all healthcare providers and patients remain safe and receive the best treatment possible. Our Diversion Trends Report shines a light on what’s going on within hospitals and health systems when it comes to medication use, which can bring awareness to some of the issues that may be occurring on a larger scale and lead to changes within organizations that improve health and safety.”

The full report can be viewed here.

About  Kit Check, The Medication Intelligence™ Company 

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™ solutions 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 950 U.S. and Canadian hospital partners have adopted Kit Check solutions to solve the most challenging of healthcare problems. Kit Check Solutions help providers save time, manage inventory, prevent diversion at their facilities, save money on medication spend, and ensure patient safety. More information about Kit Check and our software solutions can be found at



Hannah Fier
Matter Health for Kit Check