Best Practices for Monitoring Diversion in Retail Pharmacies

Retail pharmacies face unique challenges in preventing drug diversion, requiring tailored strategies to ensure compliance and safety. By adopting proactive monitoring, leveraging technology, and fostering collaboration, health systems can protect patients, staff, and their organizations from significant risks. 

This post outlines key best practices for monitoring diversion in retail pharmacies, focusing on what to look for in daily operations and how to build a resilient prevention strategy.

Shift from Manual to Proactive Monitoring

In many hospital-owned retail pharmacies (HRPs), diversion monitoring still relies on time-consuming, manual processes like sifting through reports and reconciling spreadsheets. These methods are not only inefficient but also prone to error and inconsistency, leaving dangerous gaps in oversight. A modern approach requires a shift toward proactive, data-driven monitoring that automates tasks and provides valuable insights.

Key Metrics to Monitor

Here is a checklist of high-risk areas to monitor when detecting potential diversion: 

🚩 Inventory Adjustments: Watch for frequent, small corrections, vague justifications, or patterns tied to specific staff.

🚩 Excessive Dispensing: Look for unusual activity, like one staff member dispensing more controlled substances than peers or patterns inconsistent with the pharmacy’s location and patient population.

🚩 Anomalous Ordering: Review purchasing records for drugs that don’t have corresponding dispensing records or show unusually large order quantities. 

🚩 Suspicious Prescribing: Monitor spikes in controlled substance prescriptions from specific providers or trends that don’t align with their specialty.

🚩 Inventory Counts: Ensure frequent, accurate inventory counts as required by organization-determined policies.

Foster Collaboration Across Teams

Effective diversion monitoring cannot exist in a silo. It requires a collaborative, interdisciplinary approach that integrates retail pharmacy into the health system’s broader oversight structure.

Create a Retail Oversight Group

Many health system diversion committees focus primarily on inpatient settings, leaving retail pharmacies underrepresented. To close this gap, organizations should establish a dedicated oversight group for hospital-owned retail pharmacies, either as a subcommittee of the main diversion team or as a standalone committee. This group should include representatives from retail pharmacy leadership, compliance, legal, security, and IT. By bringing together cross-functional expertise, this team can ensure consistent monitoring and accountability.

Standardize Tools

To ensure consistent monitoring across all hospital-owned retail pharmacies, the oversight committee should develop and implement standardized tools. Two essential resources include a Risk Rounds Documentation Checklist and a DEA Preparation Binder. 

• Risk Rounds Documentation Checklist helps track compliance with internal policies by verifying double signatures on controlled substance invoices, ensuring accurate cycle counts, and properly documenting medication returns. 
• DEA Preparation Binder serves as a centralized repository for all documentation required during a DEA inspection, such as licenses, power of attorney forms, inventory records, and purchasing and disposal logs. 

Build a Stronger Diversion Prevention Strategy

Retail pharmacies must meet the same high standards as inpatient settings. By implementing these best practices, health systems can close critical gaps in diversion prevention and enhance safety across the board.

For more detailed strategies, download our white paper, “Preventing Drug Diversion in Hospital-Owned Retail Pharmacies.”