Diversion of Controlled Drugs in Hospitals: A Scoping Review of Contributors and Safeguards
Drug losses and theft from the healthcare system are accelerating; hospitals are pressured to implement safeguards to prevent drug diversion. Thus far, no reviews summarize all known risks and potential safeguards for hospital diversion. Past incidents of hospital drug diversion have impacted patient and staff safety, increased hospital costs, and resulted in infectious disease outbreaks. We searched MEDLINE, Embase, PsycINFO, CINAHL, Scopus, and Web of Science databases and the gray literature for articles published between January 2005 and June 2018. Articles were included if they focused on hospital settings and discussed either: (1) drug security or accounting practices (any drug) or (2) medication errors, healthcare worker substance use disorder, or incident reports (only with reference to controlled drugs). We included 312 articles and extracted four categories of data: (1) article characteristics (eg, author location), (2) article focus (eg, clinical areas discussed), (3) contributors to diversion (eg, factors enabling drug theft), and (4) diversion safeguards. Literature reveals a large number of contributors to drug diversion in all stages of the medication-use process. All health professions and clinical units are at risk. This review provides insights into known methods of diversion and the safeguards hospitals must consider to prevent them. Careful configuration of healthcare technologies and processes in the hospital environment can reduce the opportunity for diversion. These system-based strategies broaden the response to diversion beyond that of individual accountability. Further evidence is urgently needed to address the vulnerabilities outlined in this review and prevent harm.
© 2019 Society of Hospital Medicine
The United States (US) and Canada are the two highest per-capita consumers of opioids in the world;1 both are struggling with unprecedented opioid-related mortality.2,3 The nonmedical use of opioids is facilitated by diversion and defined as the transfer of drugs from lawful to unlawful channels of use4,5 (eg, sharing legitimate prescriptions with family and friends6). Opioids and other controlled drugs are also diverted from healthcare facilities;4,5,7,8 Canadian data suggest these incidents may be increasing (controlled-drug loss reports have doubled each year since 20159).
The diversion of controlled drugs from hospitals affects patients, healthcare workers (HCWs), hospitals, and the public. Patients suffer insufficient analgesia or anesthesia, experience substandard care from impaired HCWs, and are at risk of infections from compromised syringes.4,10,11 HCWs that divert are at risk of overdose and death; they also face regulatory censure, criminal prosecution, and civil malpractice suits.12,13 Hospitals bear the cost of diverted drugs,14,15 internal investigations,4 and follow-up care for affected patients,4,13 and can be fined in excess of $4 million dollars for inadequate safeguards.16 Negative publicity highlights hospitals failing to self-regulate and report when diversion occurs, compromising public trust.17-19 Finally, diverted drugs impact population health by contributing to drug misuse.
Hospitals face a critical problem: how does a hospital prevent the diversion of controlled drugs? Hospitals have not yet implemented safeguards needed to detect or understand how diversion occurs. For example, 79% of Canadian hospital controlled-drug loss reports are “unexplained losses,”9 demonstrating a lack of traceability needed to understand the root causes of the loss. A single US endoscopy clinic showed that $10,000 of propofol was unaccounted for over a four-week period.14 Although transactional discrepancies do not equate to diversion, they are a potential signal of diversion and highlight areas for improvement.15 The hospital medication-use process (MUP; eg, procurement, storage, preparation, prescription, dispensing, administration, waste, return, and removal) has multiple vulnerabilities that have been exploited. Published accounts of diversion include falsification of clinical documents, substitution of saline for medication, and theft.4,20-23 Hospitals require guidance to assess their drug processes against known vulnerabilities and identify safeguards that may improve their capacity to prevent or detect diversion.
In this work, we provide a scoping review on the emerging topic of drug diversion to support hospitals. Scoping reviews can be a “preliminary attempt to provide an overview of existing literature that identifies areas where more research might be required.”24 Past literature has identified sources of drugs for nonmedical use,6,25,26 provided partial data on the quantities of stolen drug,7,8 and estimated the rate of HCW diversion.5,27-29 However, no reviews have focused on system gaps specific to hospital MUPs and diversion. Our review remedies this knowledge gap by consolidating known weaknesses and safeguards from peer- and nonpeer-reviewed articles. Drug diversion has been discussed at conferences and in news articles, case studies, and legal reports; excluding such discussion ignores substantive work that informs diversion practices in hospitals. Early indications suggest that hospitals have not yet implemented safeguards to properly identify when diversion has occurred, and consequently, lack the evidence to contribute to peer-reviewed literature. This article summarizes (1) clinical units, health professions, and stages of the MUP discussed, (2) contributors to diversion in hospitals, and (3) safeguards to prevent or detect diversion in hospitals.
