The CDC has officially declared a prescription painkiller overdose epidemic. According to this article, diversion is “a major driver” of this abuse. In the first of two TJC articles this month on the topic, the authors pay particular attention to the harmful effects of diversion on patients and staff.  Since diversion often involves substitution and/or dilution of a patient’s medication, they are more vulnerable to less effective care, more discomfort, infections and more.  Staff involved in diversion are more likely to suffer physically and emotionally as a result of personal addiction and professional/career  destruction.  In response to this growing crisis and potential risk hospitals are strongly encouraged to develop and rigorously maintain measures to prevent diversion.  This should include implementing a formal prevention program that addresses risk points for diversion in every phase of medication management.  A sidebar on page 9 lists a number of TJC standards (especially MM.01.01.03, MM.03.01.01 and MM.05.01.11) that could help underpin a program.  However, the authors point out that a particularly critical factor in the success of such programs will be staff education. Staff  need to clearly understand how to keep medications secure, recognize the signs of potential addiction and/or diversion and know what to do if they witness or suspect diversion is occurring.
Tip: Consider conducting an FMECA on your medication management system that focuses on diversion failure points
Tip: See also: Averting Drug Diversion: How to recognize and prevent medication theft by staff below and the comment section of this review for  more info/details.