Drug Diversion is a Patient Safety Problem

Medication substitution and tampering are difficult to detect methods of drug diversion.


Drug Diversion is a Patient Safety Problem

PUBLISHED: March 17, 2022

Amanda Hays, PharmD., MHA, BCPS, CPHQ, FASHP

Associate Director, Medical Affairs

Medication Management Solutions

Hidden Risks

A hospitalized patient rings the call bell and requests a pain medication. The nurse arrives to administer the medication and within 30 minutes, the patient begins to feel some pain relief but not as much as with the prior doses he received. The patient doesn’t realize that the oxycodone/paracetamol tablet they had been ordered to receive has been substituted with acetaminophen.¹

Another patient undergoes an elective surgery and successfully recovers.  About six weeks later, the patient felt sick and went to the urgent care center. Blood tests showed the patient had hepatitis C. The medical center explained that one of their employees tampered with the syringes used during the surgery, exposing the patient to a blood borne infection.²

In the bathroom, a syringe is found that is unlabeled with drops of blood on the floor.  The housekeeper places it in the syringe disposal bin located on the wall without notifying anyone.³

These cases⁴ are just a few examples of the types of drug diversion that have been reported in the last several years.  Each of these cases could have broader risks for patient safety leaving patients with untreated pain, needlesticks, or even infectious complications.⁵



Medication substitution and tampering are difficult to detect methods of drug diversion.6 In the last 20 years, several high-profile cases have highlighted these risks to patients. The Centers for Disease Control and Prevention (CDC) maintains a list of outbreaks of infectious diseases associated with drug diversion where the CDC and state or local health departments have assisted in investigations.5 Data from 1983-2018 highlights 13 unique instances of drug diversion by healthcare workers that led to 222 cases of viral (Hepatitis C) or bacterial infections. These infectious cases, however, are not the only potential patient safety risks due to healthcare worker diversion. 

In cases of medication substitution or tampering, patients may receive less than ordered or no medication leaving them with untreated pain.7 An additional risk, regardless of the type of diversion, is that the patient may be receiving their healthcare by an impaired healthcare worker who may make other medical errors due to their impairment.7

Some signs of diversion may be noticeable, such as a caregiver who appears impaired or intoxicated.8  Other, subtle signs may be found when organizations perform a root cause analysis. Unfortunately, in many cases, peers were concerned about the diverting caregiver long before they are detected but did not speak up. They may not speak up, believing that someone else is responsible for addressing this issue, because they are concerned that their colleague may lose their license or job or because they simply cannot believe that their colleagues would be involved in drug diversion.6, 7,8

Available data demonstrate that 10-15% of the healthcare workforce experiences alcohol or substance use disorder at some point during their career.9  In 2019, the BD Institute for Medication Management Excellence launched a survey of over 650 healthcare executives and providers about hospital drug diversion. Importantly, workplace stress makes health care providers more vulnerable to substance use disorder. Even more concerning perhaps is that in that survey 78% of responders stated they know a coworker stressed to the breaking point and although 74% of providers are comfortable seeking help to manage stress, only 39% sought out help.10 Stress, pressures, and trauma after two years of dealing with COVID-19 surges and fatalities, may increase the likelihood of healthcare worker diversion.11  As healthcare organizations expanded the intensive care units and more caregivers were provided access to potent opioids, new opportunities for diversion developed.11

Through root cause analysis12 after a drug diversion case, a healthcare organization may uncover how a healthcare worker diverted in a specific case. Far less is known about why a healthcare worker would risk their career or a patient’s safety. Some possibilities include:

  1. Misjudged risk11 -  many times healthcare workers with substance use disorder may not recognize that they are placing patients at risk by their actions.  Others feel that the risk of getting caught is low because the medications were just going to be wasted (such as in the case of a medication dose that doesn’t equal the full vial contents).  These situations may lead them to incorrectly justify their diversion.

  2. Risk points in the system13 - most facilities do not audit residual waste to ensure the product being wasted is accurate.  Without accurate identification of the contents of these syringes, other healthcare workers may be witnessing a waste of saline or water without knowing the medication has been tampered. 

  3. Physical and psychological dependence11 - in many cases, the diverting healthcare worker may divert to avoid withdrawal symptoms associated with their substance use disorder (such as anxiety, hypertension, sweating, nausea, or vomiting) with the access they already have to similar medications.


How to Reduce the Risk

  1. Focus on prevention12 - ensure healthcare workers are trained on policies and procedures for handling of controlled substances.  Ensure staff are aware that they are accountable for the appropriate handling of controlled substances.

  2. Audit12 - explore ways to compare as needed (PRN) medication administration practice patterns.  Include looking for medications beyond the controlled substances that might indicate potential substitution such as acetaminophen, ibuprofen, or diphenhydramine when removed from the automated dispensing cabinets close to the time of a controlled substance.

  3. Implement diversion prevention risk rounds12 - in these rounds, evaluate for risk points in your organization’s practice by reviewing continuous controlled substance infusions security, conducting tracers of tablet and syringe injections to the patient care unit, and wasting of medications. 

  4. Engage patients in their care12,14 - patients are not always empowered to see their medications prior to having them administered.  Having the patient as a partner to describe variations in their pain patterns or asking to see the medications before they are administered may help reduce their risk of harm.

  5. Analyze waste12 - Point of care waste analysis tools can be used to identify waste tampering.

  6. Plan ahead15 - consider a tabletop exercise to determine how an organization would identify patients that could have received tampered medications and determine the right members of the multidisciplinary team needed to address these potential scenarios.


Concluding Thoughts

March 13-19th is National Patient Safety Awareness Week. This Patient Safety Week, we encourage you to take a deeper look at your organization’s practices with controlled substances and consider how diversion prevention methods could be strengthened to reduce the likelihood of patient harm. Take the opportunity this week to review the ASHP Guidelines on Prevention of Diversion in Hospitals.13 These guidelines give an excellent framework for hospitals to get started with their diversion prevention programs.13


  1. Controlled Substance Diversion and Monitoring in the Hospital. Available at . Accessed March 10, 2022.
  2. A hospital staffer diverted drugs,  which gave me hepatitis C. That happens more often than you think. Available at . Accessed March 10, 2022.
  3. Health Care Diversion Incident 33918. Available at Accessed March 10, 2022.
  4. Healthcare Diversion- Find Incidents in your area.  Available at:  Accessed March 8, 2022.
  5. Drug Diversion Puts Patients at Risk for Healthcare-Associated Infections.  Available at:  Accessed February 25, 2022.
  6. Drug Diversion and Impaired Health Care Workers.  The Joint Commission Quick Safety, Issue 48, April 2019.
  7. Drug Diversion in Healthcare.  An N J. May 2021. 15, 5; 26-30
  8. American Association of Nurse Anesthesiology.   Reporting Impaired Colleagues.  Available at:  Accessed March 1, 2022.
  9. Baldisserri MR. Impaired healthcare professional.  Crit Care Med 2007; 35(suppl):S106-16.
  10. BD Institute for Medication Management Excellence.  Health Care’s Hidden Epidemic: A Call to Action on Hospital Drug Diversion. BD; 2019.
  11. Burger M.  Drug Diversion and COVID-19.  Compliance Today; Feb 2021.  Available at  Accessed March 9, 2022.
  12. Brummond PW, et al.  ASHP Guidelines on Preventing Diversion of Controlled Substances.  Am J Health Sys Pharm 74, 5 (2017) 325-348.
  13. Former nurse admits to thefts, dilution of pain meds. Available at  Accessed December 2, 2021.
  14.  Involve Patients in Medication Checks.  Institute for Healthcare Improvement.  Available at Accessed March 9, 2022.
  15. ASC Drug Diversion Exercise Facilitator Guide.  New Jersey Department of Health.  Available at   Accessed March 9, 2022.