Drug diversion risks patient safety, preventing patients from receiving prescribed medications, and could result in exposure to blood-borne pathogens and other risks.
Although drug diversion is not a new concept, ways to identify, investigate, and respond to these events are evolving. While the roles and responsibilities for drug diversion planning and response are well defined, the role of the infection preventionist (IP) is frequently not well defined.
Drug diversion and its effects on hospitals and patients
Drug diversion is the theft or deviation of a prescription medication from its intended path from the manufacturer to patients or facility itself. While drug diversion can happen even before the medication arrives at the facility to sell, the risk to patient safety in healthcare settings occurs when healthcare personnel (HCPs) illegally obtain medications for personal use.
Hospitals bear the fiscal impact in many ways:
- Non-reimbursed replacement medications
- Impaired staff and absenteeism
- Fines associated with the Drug Enforcement Administration (DEA) or Centers for Medicare and Medicaid (CMS)
- Negative press
And, drug diversion harms patients in several ways:
- Denied medications that increase suffering or lead to patient harm
- Inaccurate medical record documentation that impacts care plans
- Patient safety impacts due to impaired healthcare workers
- Exposure to infectious diseases if injectable medications are involved
The case of an alleged drug diversion in Medford, Oregon underscores both the impact to individual patients and their families and the hospital. With 44 identified patients to date and 16 deaths related to bloodstream infections, a nurse stands accused of swapping tap water for narcotics occurring between 2002 and 2023.
How is drug diversion identified in hospitals?
Drug diversion detection can be challenging. The signs and symptoms of impaired healthcare workers are illustrated in 2019 HAI Council of State and Territorial Epidemiologists Drug Diversion Toolkit, Appendix 8. The DEA states an employee “has an obligation” to report suspected diversion. Despite methods to report anonymously, HCPs may be in denial that a co-worker would engage in drug diversion activity, have concerns about retribution, or be wary about being involved in an investigation. In the case of the Medford case, a spike in central-line associated bloodstream infections (CLABSIs) may have been a warning sign. A news report in June 2024 indicated the hospital reported a significant rise in identified CLABSIs.
Healthcare associated infection (HAI) surveillance is a standardized, consistent method used by IPs to identify unusual trends of outcome measures, positioning the IP in an integral role of drug diversion identification. Electronic surveillance systems, such as Sentri7 Drug Diversion, use machine learning and alerts to further support the identification of suspected diversion activity down to the individual level.
What is the infection preventionist’s role in drug diversion?
Infection preventionists (IPs) are well-positioned to identify unusual infection clusters or outbreaks. IPs are the hospital resource for identifying mechanisms of disease transmission and routinely perform surveillance. They may observe an uptick in bloodborne infections within hospitalized (or recently hospitalized) patients without known risk factors, often a red flag requiring public health department notification. IPs frequently collaborate with health department officials and are aware of the mechanisms to report unusual occurrences.
In many healthcare facilities, the role of the infection prevention and control (IPC) department is unclear. IPs may learn of an investigation only when it is time to notify potentially exposed patients. IPs may not know what their role should be in drug diversion planning and response, see the benefit of participating, believe they don’t have time, or be overlooked when the drug diversion committee is formed. The CTSE Toolkit, developed in response to an integrated Drug Diversion Workgroup to “define the role of state, local and territorial public health agencies” describes the identification and response to drug diversion activities involving injectable medications, those at greatest risk of blood-borne pathogen transmission to patients, and highlights how an IP can support planning and response.
A hospital’s drug diversion program often lives within the pharmacy department, reporting to senior leadership. A steering committee involving risk management, legal, nursing, compliance and others develop goals, policies, and procedures. Leadership support is essential, especially when drug diversion events require escalation. A drug diversion response team has a clear understanding of workflows and medication management. The response team is deployed in the event of an actual or suspected drug diversion event. Participation from security, risk management, occupational health, medicine, IPC, and others will provide a strong, coordinated, response. Ideally, IPs will support the response by conducting surveillance activities (such as deep dives into previous microbiology reports) and be a resource when assessing patient risk.
