Drug Diversion or Bad Habits?

Packs of pillsYou have been asked by the CQI (continuous quality improvement) committee to initiate a weekly review of accountability for administration of controlled substances.  Your facility recently installed an automatic dispensing cabinet (ADC) in the clinic to store controlled substances. Nurses withdraw medication from the cabinet that corresponds to a specific patient order.  A feature of the ADC is that every transaction involving the administration of narcotics is recorded electronically and counts are verified at the time of each transaction.

Your first step is to review a report of all transactions that took place last week. The report lists each medication and whether it was removed, returned or wasted.  The information included with each of these transactions is the date and time, the order number, the quantity, the patient identifier, and the identity of the nurse responsible for the transaction.  You randomly select eight medication administration events to review.  The results are surprising.

Problems with accountability for controlled substances are identified in four of the eight instances reviewed. These problems are:

1. The nurse removed two tablets of tramadol HCL when the patient’s order was only for one tablet. On the medication administration record (MAR) only one tablet was documented as given. The second tablet was not accounted for.

2. The nurse removed a dose of clonazepam for a patient at 5 pm when the order was only for a morning dose. There was no documentation that the dose removed from the cabinet at 5 pm was ever given to the patient or returned to the cabinet later.

3. One nurse removed a dose of clonazepam at 5:30 AM but it was recorded as given by another nurse at 9:00AM.

4.  A nurse records wasting 50 tablets of tramadol HCL at 10:20 PM. There is no record that another nurse witnessed the event and the number of tablets wasted is not consistent with the count of tramadol HCL kept in the cabinet.

You report these findings to the CQI committee and after some discussion an action plan is developed which will continue monitoring and follow up of discrepancies. The plan also includes informing nursing staff about the methods that are used to monitor accountability for administration of controlled substances, the definition of drug diversion and associated risk behaviors, and recommended best practices to improve accountability for controlled substances.

Nurses who fail to account for controlled substances violate the state nurse practice act, the Controlled Substances Act and may be at risk of criminal sanctions as well. Drug diversion is defined by the U.S. Department of Justice simply as diverting drugs from their original purpose (2013). A discrepancy between the patient’s MAR and the controlled substance log can be sufficient evidence to prove drug diversion (Mooney, 2013).  A discrepancy is lack of documentation to account for each step in the administration of a controlled substance after its removal from the narcotic cabinet. Instances 1, 2 and 4 described above are discrepancies because there is insufficient documentation to verify the disposition of each dose removed from the ADC.

Other practices that are associated with increased potential for drug diversion include:

  • Excessive amounts of controlled substances signed out
  • More sign outs by a particular nurse
  • Lack of waste or excessive wasting
  • Documentation of medication administered for pain that does not correspond to the patient’s rating of pain.
  • Lengthy periods of time between sign out and administration to the patient (Mooney, 2013; LaFerney, 2010; Vrabel, R. 2010).

Instance 3 described above involved a controlled substance that was signed out four hours before it was administered. It also was given by a nurse other than the one who signed it out. Instance 4 involved excessive wasting and was not verified by a second nurse.

After further follow up of each of these instances no additional evidence is found to support a conclusion that any of these nurses were diverting controlled substances. Instead each involved poor work place practices, time and staffing constraints. The nursing staff was surprised at how many problems were brought to light by simply monitoring the controlled substance log against the MAR and discussed the steps they would take to better account for the disposition of each medication dose. Your subsequent audits provide feedback and evidence of improvement in accountability for controlled substances.

Additional resources on accountability for controlled substances and recommendations to prevent and detect diversion can be obtained at the Institute for Safe Medication Practices and from a series of articles that appeared in Volume 42 of the journal, Hospital Pharmacy, published in 2007 (McClure et.al. 2011). For more on best practices for medication administration in the correctional setting see Chapter 4 of the Essentials of Correctional Nursing which can be ordered directly from the publisher. If you use Promo Code AF1209 the price is discounted by $15 off and shipping is free.

Have you had success solving problems with accountability for controlled substances that you would like to share with others? If so please tell us about it by writing in the comments section of this post.


LaFerney, M.C. (2010) Dealing with drug diversion. Reflections on Nursing Leadership. 36 (2).

McClure, S.R.; O’Neal, B.C.; Grauer, D.; Couldry, R.J. (2011) Compliance with recommendations for prevention and detection of controlled-substance diversion in hospitals. American Journal of Health-System Pharmacy. 68: 689-694

Mooney, D. H. (2013). Investigating and Make a Case for Drug Diversion. Journal of Nursing Regulation. 4 (1): 9-13.

U.S. Department of Justice, Office of Diversion Control. (2013). Code of Federal Regulations 21 Part 1300. Retrieved 5/30/2013 from  http://www.deadiversion.usdoj.gov/21cfr/cfr/2100cfrt.htm.

Vrabel, R. (2010) Identifying and dealing with drug diversion. Health Management Technology. 31 (12):1-5

Photo Credit: © oksix – Fotolia.com

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