How effective is your Drug Diversion Surveillance Program?
According to the 2025 State of Drug Diversion Report, about two-thirds of healthcare participants say they are either “not confident” or only “somewhat confident” in their organization’s drug diversion program’s effectiveness. That number holds even at large hospital systems with dedicated diversion staff.
Controlled substances are abundantly available and accessible in hospitals and healthcare organizations. Identifying and preventing diversion without a comprehensive surveillance program in place is genuinely difficult, and the consequences of a gap, whether to patient safety, staff wellbeing, or regulatory standing, are serious.
The Joint Commission’s Quick Safety Issue 48 outlines five priority areas for a successful Controlled Substance Diversion Prevention Program (CSDPP)
- Leadership Oversight
- Legal and Regulatory Requirements
- Monitoring and Surveillance
- Automation and Technology
- 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
What should we assess here? Whether the technology in place can detect diversion in real time, not just in retrospect, and whether it supports cross-disciplinary workflows.
Not all drug diversion surveillance solutions are built the same way. One of the most meaningful distinctions is the difference between supervised and unsupervised machine learning.
Supervised machine learning works with labeled data, meaning metrics are pre-defined as “normal” or “abnormal.” It can catch known diversion patterns but tends to miss new ones.
Unsupervised machine learning finds and evaluates patterns within data in real time without predefined labels. It identifies groupings within a dataset and flags outliers against a normalized baseline that itself evolves as behavior changes over time. In practice, this means it can surface something like a nurse who gradually increases override frequency on night shifts, even when no single transaction looks alarming on its own.
Identification matters, but speed of follow-up matters just as much. Technology should also support communication between disciplines so that when an event is flagged, the right people can act on it quickly.
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.