Perioperative Drug Diversion Surveillance Recommendations

Focusing drug diversion surveillance on perioperative areas is important since procedural settings are considered at higher risk for diversion.


Drug Diversion is a Patient Safety Problem

Perioperative Drug Diversion Surveillance: Unique Challenges

Samantha Bastow - PharmD, MBA and Taylor Diani, MBA, MSN, RN


Research estimates that 10-15% of medical providers will abuse or misuse drugs or alcohol at some point in their career.1 Some of these providers may obtain substances of abuse through drug diversion, which is defined as “when prescription medicines are obtained or used illegally” according to the CDC.2 Such action places patients and health care providers at significant risk.3  Although the risk is clear, the methods by which health systems lower the risk and detect drug diversion are not so simple. For this reason, drug diversion in healthcare continues to be an area of focus for The Joint Commission, American Society of Health-System Pharmacists (ASHP), Anesthesia Patient Safety Foundation (APSF), American Association of Nurse Anesthesiology, and the Institute of Safe Medication Practices (ISMP).3,4,5,6,7 Given that establishing a robust drug diversion surveillance program is a tall task for hospitals, a great place to start is surgical areas since they are considered at higher risk for diversion.3



Unique risks in the perioperative and procedural areas

There are several reasons why the perioperative space is a high-risk area for drug diversion, including:

It is estimated that 51.4 million inpatient procedures8 and 53.3 million outpatient procedures are performed each year.9 During such procedures, anesthetics and analgesics (e.g., opioids) are delivered by anesthesiologists, certified nurse anesthetists, and registered nurses; in fact, research shows that nurse anesthetists alone deliver 50 million anesthetics per year.10  This high volume of access to medications causes a high frequency of opportunity for diversion.

Anesthesia providers have access to large quantities of medications with minimal oversight regarding medication dosing, administration, and waste.3,5 In contrast to the workflow followed in other patient care areas (requiring provider order entry, pharmacist verification, nurse dispense per verified order, and waste requiring observation by a second provider), all of these steps may be performed by a single provider.11  Further, the anesthesia providers are often stationed “behind the curtain” at the head of the patient bed where visibility to other providers is restricted. Therefore, chain of custody in the perioperative space is often lacking independent verification. Research has shown that anesthesiologists have a higher rate of substance abuse, especially that of intravenous opioids, because of their ease of access.1


Unique behaviors associated with drug diversion 

The uniqueness of the perioperative space coupled with creative techniques that healthcare workers employ when diverting controlled substances make it much harder for organizations to detect diversion. Therefore, it is important for leaders to be aware of behaviors associated with diversion. An article from Nursing Critical Care12 and the “See Something, Say Something” campaign13 both provide several examples of ways that medications may diverted and behaviors that may be exhibited:


  • Consistently uses more drugs for cases compared to peers
  • Higher patient pain score compared to peers
  • Patients with unusually significant or uncontrolled pain after procedure
  • Inappropriate drug choices and doses for patients
  • Frequent breaks/trips to bathroom, coming in early/staying late for shifts
  • Anesthesia record does not reconcile with drug dispensed and administered
  • Frequent volunteering to administer narcotics and/or relieve colleagues of cases with opioid orders
  • Creating medication discrepancies, removing medications, and claiming the dispensing cabinet was filled incorrectly
  • Times of cases do not correlate when provider dispenses drug from automated dispensing cabinets (ADC)
  • Drugs, syringes, needles improperly stored
  • Signs of medication tampering, including broken vials returned to pharmacy
  • Substituting opioid with a non-scheduled pain medication; may commonly pull opioid and non-scheduled medications at the same time
  • Theft from multidose vial; high incidence wastage of medications compared to peers
  • Documentation of whole dose waste and/or cancelled transactions for drug removal
  • Theft of medications that a patient brought in from home
  • Removal of medications for a discharged or transferred patient


Recommended Practices for Drug Diversion Prevention and Detection

The ASHP Guidelines on Preventing Diversion of Controlled Substances provides a framework that organizations can use to develop controlled substance monitoring programs. These guidelines highlight the importance of implementing drug diversion detection and prevention through all aspects of medication use, with special attention to high-risk surgical settings.3

  1. Use of automation and technology: The use of ADCs is recommended in all high-risk locations and access to controlled substances within the ADCs should be limited to specific providers.3  ADCs restrict access to medications, allow for auditing of medication dispenses and highlight when medications may be missing (e.g., discrepancies). Additionally, drug diversion monitoring software may utilize data from ADCs which can assist with monitoring chain of custody and inventory management for controlled substances. ISMP guidance for safe medication handling in the perioperative area also supports restricted and controlled access of preoperative medications and their storage in secured cabinets such as locked ADC pockets.7

  2. Monitoring and surveillance: A Controlled Substance Diversion Prevention Program (CSDPP) should be implemented and include assigned committee members to determine the diversion data points necessary for review and audit. It is expected that the program be an ongoing, cyclical process to include review of controlled substance (CS) compliance, surveillance of trends identified during the review, investigation and reporting of the trends, a resolution of the investigation, and the implementation of continued systems improvements identified throughout the process. 3 It is recommended that surveillance activities are cross-collaborative efforts and performed at a regular cadence.  

  3. Returns and waste: Given that drug diversion by means of the wasting process is a known issue, waste should be verified by another provider and documented. Facilities should also perform random waste testing in high-risk areas like the OR. 3 A facility may choose to purchase equipment to perform testing on-site or send samples to an outside lab for testing to avoid the upfront capital expense. Lastly, some facilities may initially perform “for cause” testing but then progress towards a more mature model of sampling various medications, providers, and including more patient care areas at a regular cadence.11 Regardless of which method is chosen, it is crucial to follow chain of custody for waste samples to maintain integrity for investigations. 

  4. Leadership support and multi-disciplinary collaboration: Establish resource allocation and accountability for all team members while also creating a speak-up culture (e.g., see something say something campaign). To best support compliance in the perioperative space, it is key to include an anesthesia leader as a program champion for program oversight.3

  5. Ongoing education: To highlight the importance of drug diversion, education should be provided at a regular cadence to all team members. APSF has provided guidance for specific topics of focus and means of disseminating education.5




Drug diversion is multifaceted and difficult to address. Focusing on areas of high risk is a key step in the process; one such area is the perioperative space given the unique workflows and challenges. ASHP guidelines state that “ultimately, each organization is responsible for developing a CSDPP that complies with applicable federal and state laws and regulations and applies technology and diligent surveillance to proactively prevent or detect diversion”.3 In addition, health system leadership should educate staff regularly on diversion behaviors and encourage a speak-up culture that empowers staff to tackle this important issue together. Having a multidisciplinary team approach to ensure monitoring and surveillance at a regular cadence are important first steps. Developing a CSDPP is a journey that requires collaboration and a system of checks and balances. 


  1. Baldisserri MR. Impaired healthcare professional. Crit Care Med. 2007;35(suppl):S106-116.
  2. Risks of healthcare-associated infections from drug diversion. Centers for Disease Control and Prevention. November 26, 2019. Accessed January 20, 2023.,use%20put%20patients%20at%20risk.
  3. Clark J, Fera T, Fortier C, et al. ASHP guidelines on preventing diversion of controlled substances. American Journal of Health-System Pharmacy. 2022;79(24):2279-2306. doi:10.1093/ajhp/zxac246
  4. Quick safety issue 48: Drug diversion and impaired health care workers. The Joint Commission. April 15, 2019. Accessed January 20, 2023.
  5. Merry AF, Johnson WD, Morris WM, Gelb AW. The SAFE-T Summit and the International Standards for a Safe Practice of Anesthesia. APSF. Feb 2019; 33(3), 92-94.
  6. AANA Position Statement. Addressing Substance Use Disorder in Anesthesia Professionals.  AANA 2021; special edition, 1-12.
  7. Institute for Safe Medication Practices (ISMP). ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings. ISMP; 2022. Accessed January 20, 2023. Guidelines for Safe Medication Use in Perioperative and Procedural Settings | Institute For Safe Medication Practices (
  8. Number of all-listed procedures for discharges from short-stay hospitals, by procedure category and age: United States, 2010.  CDC/NCHS National Hospital Discharge Survey, 2010. 2015. Accessed January 20, 2023.
  9. Cullen K, Hall M, Golosinskiy A. Ambulatory Surgery in the United States, 2006. National Health Statistics Reports. January 28, 2009. Accessed January 20, 2023.
  10. Certified Registered Nurse Anesthetists Fact Sheet. October 5, 2022. Accessed January 20, 2023.
  11. Bickham P, Golembiewski J, Meyer T, Murray CG, Wagner D. ASHP guidelines on Perioperative Pharmacy Services. American Journal of Health-System Pharmacy. 2019;76(12):903-920. doi:10.1093/ajhp/zxz073
  12. Pfrimmer DM. Recognizing and preventing drug diversion. Nursing Critical Care. 2015;10(6):5-9. doi:10.1097/01.ccn.0000472850.93302.
  13. Nyhus J. Drug diversion in healthcare. American Nurse Journal. 2021;15(5):26-30.
  14. Warner DO, Berge K, Sun H, Harman A, Hanson A, Schroeder DR. Substance use disorder among anesthesiology residents, 1975-2009. JAMA. 2013;310(21):2289. doi:10.1001/jama.2013.281954
  15. van Pelt M, Meyer T, Garcia R, Thomas BJ, Litman RS. Drug diversion in the anesthesia profession. Anesthesia & Analgesia. 2018;128(1). doi:10.1213/ane.0000000000003878 
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