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substitution, deliberate removal of a larger dose, premature replacement of patient-controlled analgesia (PCA) pumps or of IV drips, and theft from sharps containers.
Because most commonly diverted substances cause dependence, di- verters need to increase drug dos- ages to quell their addiction. Drug diversion methods then become more daring. Tactics include access- ing medication when not requested, removing medication from a dis- charged patient, removing a dupli-
cate dose, reusing a fentanyl patch, falsifying a verbal or electronic order, using a colleague’s login to access an ADC, and tampering with or substi- tuting the controlled medication.
Substitution poses the greatest hazard to patients. In addition to denial of needed medication, sub- stitution may cause transmission of bloodborne pathogens. Substitution occurs at the ADC, a patient’s bed- side or anywhere a controlled drug is in transit. Diverters may access cabinets through null transactions
or purported cycle counts, then substitute the contents of pill vials or syringes. In several cases, sub- stitution occurs in procedural areas when medications are laid out in preparation for administration.8
Model for Prevention & Detection
In response to increasing drug di- verters and the devastating harm to patients, the Mayo Clinic created the Drug Diversion Intervention and Response Team (D-DIRT). Today, the D-DIRT program is considered the model for dealing with opioid- addicted physicians, nurses and technicians and the risk they pose to patients.
To combat drug diversion, the Mayo Clinic recommends:
1. Establish a zero tolerance policy for theft of any drug and from anywhere, including a zero tolerance policy for any worker who fails to properly witness a coworker disposing a drug that is not ultimately given to a patient. Zero tolerance policies include immediate termination upon viola- tion of such policies.
2. Make friends with law enforcement agen- cies, including the local police and the DEA, who can process search warrants of employees’ homes and cars to help prove a case, and ensure the case is on record for prospective employers.
3. Employ a 24-hour diversion hotline for workers to report suspicious behavior. Advertise the program with a slogan such as “Save Your Coworker’s Life” and post it on ADCs. Make sure responders have authority to take prompt and appropriate action.
4. Assemble a team similar to the Mayo’s D-DIRT. Include a full-time Medication Diversion Prevention Coordinator — speci cally, a pharmacist or a certi ed pharmacy technician — who will coordi-
In several cases, substitution occurs in procedural areas
when medications are laid out in preparation for administration.
54 | InsideOut