Dealing with Controlled Substance Diversion


by Nichole Barnes, BHI, CPhT


According to the ASHP, “Drug diversion can be defined as any criminal act or deviation that removes a prescription drug from its intended path from the manufacturer to the intended patient.” Drug diversion can happen to many people in different locations and pharmacies, and sometimes it happens with people you are close to or would never suspect. Don’t let your feelings or emotions cloud your judgment. Trust the facts and the documentation. 


Having worked several narcotic diversion cases with NCIS, DEA, and NC-SBI, let me tell you a little about dealing with narcotic diversion and investigations. 


Who Can Divert

In hospital settings, nursing staff, pharmacy staff, providers, and anesthesia staff could potentially access and divert narcotic medications. However, if automated dispensing cabinets are not configured correctly, other team members may have access to controlled substances. To help alleviate this likelihood, make sure that your respiratory medications are kept in a drawer/cabinet by themselves. Also, ensure that your role privileging allows narcotic access to only certain employees. These controlled substances should also be inventoried with a witness frequently. Removing narcotics that are not emergent or used by a patient is also imperative. Many risk management teams will also ensure that all automated dispensing cabinets have cameras to increase security. 


How Diversion Occurs 

Diversion can occur in many ways, from entering an incorrect number of refills to a machine or withdrawing a medication for a patient but never giving it to them. One of the most common ways I dealt with diversion was from a waste perspective. We had many nurses who were diverting the waste of narcotics. Anesthesia was one of the most complex groups to monitor for diversion because their documentation was not typical. Our hospital had to be very particular about the wording of our policies and procedures for OR staff and narcotic usage. After a few diversion cases, we also had to update our nursing policies regarding narcotics dispensing and wasting. 


Is Someone Diverting

Many automated dispensing cabinets have canned reports that are standard and should already be built. You need to schedule them and check them regularly. Set time each day to check wastage reports to see if there are any narcotics pulled that did not have waste documentation. Next, keep a record of staff that shows up on any of these reports. If you have repeat offenders, make sure to check their documentation more thoroughly. Also, don’t forget to check the pharmacy staff for diversion. When checking pharmacy staff, do a checks/balances report with your controlled substance safe and what was delivered to the units. Also, check for technicians frequently inventorying narcotic pockets in the automated dispensing cabinets. A narcotic investigator can often pick up on little cues before a person is reported for suspected diversion. Anytime you suspect someone of diversion, talk to your Director of Pharmacy to see if an investigation should be opened. 


Narcotic Investigations

Once a person is suspected of diversion, an entire narcotic history should be pulled for the last 30-days (or whatever timeframe your hospital has determined). The team should be notified of an open investigation if your facility has a narcotic investigations team. Also, the nurse manager and chief nursing officer should know that a nurse is involved. If the person is a pharmacy technician, ensure to run as much information as possible regarding their activity with narcotic medications. For nursing staff, run patient reports to see what patients received narcotics dispensed by the nurse. 

Once all reports have been run, it is time to go through each line with a fine-toothed comb. For pharmacy staff, you are checking for frequency and any discrepancies. For nursing staff, this is a little more complicated; each patient record should be checked for documentation of administration and waste. If the numbers from your reports don’t match the documentation in the electronic health record, you should note the discrepancy. Typically, if there were minor discrepancies from the 30-day history, I would run an additional 60-day history to be thorough. 


Reporting Diversion

Any suspected diversion confirmed by the investigation should be reported to the DEA within 24 hours and to the Board of Pharmacy per your state’s guidelines. The Board of Pharmacy will handle any investigation involving a pharmacy technician. If a nurse is suspected of diversion, a report should be filed with the Board of Nursing for your state. Make sure you check with your Director of Pharmacy to see if any other reports need to be filed.



ASHP Guidelines on Preventing Diversion of Controlled Substances. (2017). Am J Health-Syst Pharm,74(5), 325-348. doi:10.2146/ajhp160919