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Joint Commission focuses on strategies to detect, prevent drug diversion

Detection and prevention of drug diversion in health care is the focus of this month’s A look at the Joint Commission column.

Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCSEng(Hon), FRCSEd(Hon)

June 1, 2019

The Joint Commission

Drug diversion is a potential threat to patient safety for any health care facility, and because some of the most high-risk care settings include surgical suites, surgical centers, anesthesia and procedural areas, recovery rooms, and emergency departments, surgeons are among the health care professionals who need to be alert to potential drug diversion.1 Drug diversion is a medical and legal concept involving the transfer of any legally prescribed substance from the individual for whom it was prescribed to another person. Up to 10 percent of health care workers may be abusing drugs, according to statistics from the U.S. Substance Abuse and Mental Health Services Administration and the American Nurses Association.2

Safety risks

Drug diversion poses substantial risk to patients. The Centers for Disease Control and Prevention emphasizes that when prescription medicines are obtained or used illegally, individuals who use them may be exposed to diseases caused by contaminated needles and drugs. If the user is a health care worker, drugs may impair performance in the workplace. Furthermore, diverting drugs meant for patient use may result in inadequate pain relief in addition to the risks to the health care worker.3 Moreover, drug diversion can negatively affect an organization’s reputation and open it up to civil or criminal monetary penalties.

The Joint Commission recently focused on the issue of drug diversion in the April issue of its Quick Safety newsletter. The issue details patterns and trends that could indicate potential drug diversion, as well as some safety actions health care facilities can take.2

Five classes of drugs are most commonly abused, according to the U.S. Drug Enforcement Administration: opioids, antidepressants, hallucinogens, stimulants, and anabolic steroids. Fentanyl—a powerful opioid pain reliever—is the most commonly diverted drug. Other commonly diverted drugs include:4

  • Other opioids, such as morphine, oxycodone, methadone, and other hydrocodone combinations
  • High-cost antipsychotic and mental health drugs, such as aripiprazole, ziprasidone, risperidone, quetiapine, and olanzapine
  • Benzodiazepines, such as alprazolam, clonazepam, and lorazepam

Detection and prevention

Detection and prevention of diversion can be difficult—especially if an organization lacks a comprehensive controlled substances diversion prevention program.1 According to the Quick Safety newsletter, direct observation is key.2 Some of the signals of drug diversion include abnormal behaviors, an altered physical appearance, and poor job performance.

Furthermore, the Quick Safety newsletter recommends that health care facilities consider three essential components when dealing with drug diversion:2

  • Prevention—putting processes in place to guard against theft and diversion and staff education in these methods.
  • Detection—installing systems such as video monitors in high-risk areas to facilitate in early detection. It is important to consider patient privacy issues when installing these video monitors.
  • Response—establishing a culture in which staff feel comfortable with the mantra, “See something, say something.”

The topic of drug diversion was recently addressed in a Healthcare Executive article, “Two lessons learned.”1 Written by The Joint Commission’s Andrew C. Bland, MD, FAAP, FACP, medical director, healthcare quality evaluation, and Christina Balsano Wichmann, associate project director, department of standards and survey methods, the article delved into how to take the mistakes other hospitals have made in drug diversion cases and turn them into teachable moments. The lessons were to consistently follow the facility’s anti-diversion policies and provide effective controls for automated drug-dispensing machines.

The article included anti-diversion strategies from the Institute for Safe Medication Practices, such as the following:1

  • Refrain from passing along controlled substances to others to administer or waste
  • Use waste containers with small openings for disposal of sharps or pharmaceutical waste in patient care areas
  • Prohibit personal storage items (such as backpacks and purses) in areas where controlled substances are stored or disposed
  • Use technology to identify trends of drug-dispensing machines and their users
  • Require someone else to serve as a witness when controlled substances are disposed
  • Implement a rotating staff schedule to manage procurement, storage, and distribution of controlled substances


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.


  1. Bland AC, Balsano CW. Two lessons learned. March/April 2019. Healthcare Executive. Available at: www.jointcommission.org/assets/1/6/MA19_IPC_reprint_Drug_Diversion.pdf. Accessed May 1, 2019.
  2. The Joint Commission. Quick Safety, Issue 48: Drug diversion and impaired health care workers. April 2019. Available at: www.jointcommission.org/assets/1/23/Quick_Safety_Drug_diversion_FINAL2.PDF. Accessed May 1, 2019.
  3. Brummond PW, Chen DF, Churchill WW, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. Am J Health Syst Pharm. 2017;74(5):325-348.
  4. Centers for Medicare & Medicaid Services. Drug diversion in the Medicaid program—state strategies for reducing prescription drug diversion in Medicaid. January 2012. Available at: www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/downloads/drugdiversion.pdf. Accessed May 1, 2019.