In partnership with IntelliGuard Intelligent Inventory Solutions
I came to diversion investigation by a long and winding road. I started my career as a nurse and later became an attorney, working both as a clinician and as a litigator. Early in my legal and nursing careers, I became aware of diversion in health care facilities. As a nurse, I saw surgical technicians terminated for stealing fentanyl and even took care of a newborn whose father diverted his pain medication shortly after the infant had open-heart surgery. As an attorney, I discovered widespread diversion of controlled drugs by nurses at facilities in the system where I was working. As a result of these experiences, I began to develop systems to prevent diversion and ways of catching diversion when it happened. After several years of diversion prevention, detection, and response work, I made a business consulting with healthcare facilities across the country assisting them in assessing their risk and developing systems to reduce risk.
Diversion investigation is not an easy career choice. During my career, I have discovered diversion that ended the careers of award-winning nurses, newlyweds, mothers, fathers, and expectant mothers and fathers. I have had to confront friends who were diverting, ending the career of at least one good friend and several nurses with whom I had worked. Confronting even a person with whom I have no acquaintance can be heart-wrenching since I know that the confrontation may end their clinical career and even result in criminal prosecution.
On the other hand, the benefits of what I do are real, if not as immediate or obvious as the downsides. I often investigate cases of diversion that resulted in severe patient harm, with patients lingering in pain and deprived of pain medication because of diversion. I have investigated cases in which patients were exposed to disease when a diverter reused a syringe or needle between himself and the patient or substituted tap water or toilet water for the ordered medication.
The harm that I prevent is not only to patients, but to coworkers, members of the community, and even to the diverters themselves. In general, once diverters begin to use stolen drugs, they escalate their use until harm is inevitable. I have seen the spouse of a friend and coworker end his life by overdosing on diverted medication. I have known diverters who deliberately implicated coworkers by stealing their login credentials, and others who drove under the influence of diverted drugs and caused fatal road accidents. When I must confront a diverter with whom I feel sympathy, I have to remember that I am preventing outcomes such as these.
Here I will outline what it means to be a Diversion Specialist and for those who may be interested in making a similar commitment, give guidance on how they can do so. I will try to show what kinds of investigative skills and what kinds of technology are needed to investigate and to prevent diversion in healthcare facilities.
A Brief History of Diversion Prevention
In my consulting, I most often work with pharmacy and nursing leaders who are motivated by the desire to improve controlled substance handling processes. I perform reviews of drug dispensing data and clinical records that reveal patterns of usage and other behaviors associated with diversion. Many times issues of poor clinical practice are seen, practices that, particularly when widespread, make the discovery of diversion more difficult. At other times my services aren't requested in anticipation of diversion but in response to a devastating or highly publicized event involving patient harm from diversion. Such events often make national news as a result of the widespread nature of patient harm that occurred.
One such event occurred almost a decade ago when a diverting radiology technician who worked as a traveler made national news after infecting more than 40 patients with hepatitis C. The technician was sentenced to 39 years in prison in 2013 for stealing opioids and replacing them with saline-filled syringes tainted with his blood. Before his conviction, his diversion had been addressed in the workplace in a way that was not unusual at the time. His use and theft of controlled substances were handled by the Human Resources department and only resulted in termination from certain jobs with no outside reporting and investigative data available to his next place of employment. Because of this, he continued to work as a radiology technician in 18 hospitals in seven states before his initial arrest. Even still, after his arrest in 2012, 46 people in four states were diagnosed with the same strain of the Hepatitis C virus he carried, including one patient that died as a result.
After this notorious case, I saw a surge of requests for diversion risk evaluations from healthcare organizations across the country. While I was happy to have an opportunity to help, it was disappointing that I had to address the issue retroactively. If the proper procedures and education were in place before this, lives might have been saved and illnesses prevented. Beyond the patients that were infected, the diverter himself in theory could not only have been held accountable but had an opportunity for recovery as well.
As time passes, the risk of diversion of controlled substances among healthcare workers has not lessened. New challenges to health care facilities such as the COVID-19 have made it difficult for facilities to give the necessary attention to diversion prevention. Developing methods of returning the needed attention to the problem at hospitals and other facilities is a major focus of my work. I advocate for each facility or health system to have a formal diversion prevention and detection program so that the focus on diversion doesn't fall by the wayside amid a crisis.
Even in the current health care climate, some basic steps can make a substantial impact on an institution's ability to prevent, detect and respond appropriately to diversion. Education and process development are key. The establishment of a diversion prevention committee and a diversion response team are essential.
The creation of a full-time drug diversion specialist position is often necessary; even in very small facilities, this role is critical, even if it isn't full-time. Next, and perhaps most importantly, mandatory training of all staff with access to controlled substances, including information on institutional policies and expectations for controlled substance handling, the reasons for those expectations, how to identify indicators of diversion by a colleague, and how to self-report or report concerns about a teammate.
A comprehensive multidisciplinary approach to surveillance and auditing is also required. In many instances, an external audit to ensure compliance with DEA requirements and with industry best practices is also beneficial. Almost universally when I am on site I find that controlled substance practices are not what managers at the organization believe them to be.
There is a general tendency for risky and sloppy practices to creep into use when ongoing education is not required. While good policies and procedures may be in place, workers may develop shortcuts or workarounds that increase the risk if they aren't closely monitored. They often don't appreciate the magnitude of the risk or don't understand the reasons for the organizational expectations.
Challenges face growing health systems, which often have disparate processes from facility to facility. Uniformity in technology and approach to diversion is essential since dissimilar processes are unwieldy and create substantial risk. Developing a uniform diversion prevention, detection, and response plan for all facilities in a system is labor-intensive but well worth the effort.
An external review allows the organization to gain an objective picture of where they stand. In my experience, these risk assessments often result in an extensive list of recommendations of varying levels of priority. A key takeaway is that the road to effective prevention, detection, and response often requires a considerable overhaul of systems with new, and improved procedures and approaches. This type of change cannot typically be accomplished overnight.
What to Consider for the Future of Prevention
Preventing diversion is not a singular act. It requires a multidisciplinary effort. For those looking for a way to get involved, my recommendation would be to join your institutional diversion prevention effort. This might mean joining a committee, helping to pilot a new process, taking part in opioid stewardship initiatives, or pointing out harmful work practices to colleagues.
It is also important to remember that while most work in the medical field is driven by immediate compassion, diversion prevention takes a special kind of personality and character. A thick skin is needed, as well as the ability to be able to focus on the end result while handling unpleasantness along the way. Working as a diversion specialist takes patience and attention to detail. Diversion investigations are not generally processes that would make exciting entertainment to watch. Much of my time is spent in policy development and endless auditing of controlled substance transactions. Even the final confrontation of a diverter more often results in tears and sadness than in an angry or hostile interview.
In addition to investigative skills, technology plays a substantial role in the advancement of diversion prevention and investigation. Since automated dispensing cabinets have largely replaced paper records and end-of-shift drug counts, a much higher proportion of cases of diversion can be discovered. Newer technology allowing continuous tracking of medications through the facility has made it possible to complete audits without dedicating an impractical amount of staff time. Many tasks that previously required laborious manual work can now be accomplished quickly because of automation. Diversion can now be discovered at a much earlier stage, through patterns of administration, rather than through behavioral indicators of impairment, which are a very late sign of diversion. Those with an interest or skill in developing and advancing technology and analytics would be valuable members of the diversion prevention community.
Advocating for regulatory improvements is also a way to get involved. ASHP and, to some extent, The Joint Commission provide guidelines, but, besides DEA regulations and the Medicare Conditions of Participation, a national set of regulatory requirements does not exist. Without clear-cut regulatory requirements, diversion prevention, detection, and response can be an uphill battle. More than once, I have gone into a facility and had someone raise their hand and say, "unless you can point to the law that says I have to do this, I'm not interested in changing my practice." Many facilities are reluctant to appropriately report diversion for fear of inviting regulatory scrutiny. While some types of reporting are mandatory, others are open to interpretation, which gives facilities a chance to reason away the need to report. In general, regulatory bodies expect that institutions are held to the standards of the best practices available, but a more extensive regulatory framework would be very helpful.
My career has been driven by a desire to protect patients, colleagues, and the community. I hope that others with similar goals will contribute to the field in the future, whether through the application of my investigative techniques, the development of new techniques, or the development of new technologies to assist in prevention and investigation of diversion.