SPECIAL ARTICLE

Diversion of Drugs Within Health Care
Facilities, a Multiple-Victim Crime: Patterns of
Diversion, Scope, Consequences, Detection,
and Prevention
Keith H. Berge, MD; Kevin R. Dillon, PharmD, RPh; Karen M. Sikkink, CPhT;
Timothy K. Taylor, CPP; and William L. Lanier, MD
Abstract
Mayo Clinic has been involved in an ongoing effort to prevent the diversion of controlled substances from the
workplace and to rapidly identify and respond when such diversion is detected. These efforts have found that diversion
of controlled substances is not uncommon and can result in substantial risk not only to the individual who is diverting
the drugs but also to patients, co-workers, and employers. We believe that all health care facilities should have systems
in place to deter controlled substance diversion and to promptly identify diversion and intervene when it is occurring.
Such systems are multifaceted and require close cooperation between multiple stakeholders including, but not limited
to, departments of pharmacy, safety and security, anesthesiology, nursing, legal counsel, and human resources. Ideally,
there should be a broad-based appreciation of the dangers that diversion creates not only for patients but also for all
employees of health care facilities, because diversion can occur at any point along a long supply chain. All health care
workers must be vigilant for signs of possible diversion and must be aware of how to engage a preexisting group with
expertise in investigating possible diversions. In addition, clear policies and procedures should be in place for dealing
with such investigations and for managing the many possible outcomes of a confirmed diversion. This article provides
an overview of the multiple types of risk that result from drug diversion from health care facilities. Further, we describe
a system developed at Mayo Clinic for evaluating episodes of potential drug diversion and for taking action once
diversion is confirmed.
© 2012 Mayo Foundation for Medical Education and Research 䡲 Mayo Clin Proc. 2012;87(7):674-682

“Diversion” means the transfer of a controlled
substance from a lawful to an unlawful channel
of distribution or use.
Uniform Controlled Substances Act (1994)1

For editorial
comment, see
page 607
From the Department of
Anesthesiology (K.H.B.,
W.L.L.), Department of
Pharmacy (K.R.D., K.M.S.),
and Department of Safety
and Security (T.K.T.), College
of Medicine, Mayo Clinic,
Rochester, MN.

674

“Diversion” means “Any criminal act involving a
prescription drug.”
National Association of Drug Diversion
Investigators2

I

n the United States in 2010, nearly 4 billion retail prescriptions were filled, with sales totaling
$307 billion. The medication most often prescribed, 131.2 million times, was the opioid hydrocodone combined with acetaminophen.3 The opioid
oxycodone combined with acetaminophen was prescribed 31.9 million times. Although most of these
sales resulted in the legitimate, targeted administration of pharmaceutical agents to patients, a fraction
of the drugs manufactured and prescribed for patients are diverted for illicit purposes. Most drug
prescriptions are for use in the outpatient setting,
and, thus, most diversions of drugs occur there. This

problem has been well documented in multiple
publications and will not be further addressed
here.4 Although a relatively small fraction of the nation’s drug supply is administered in a health care
facility such as a hospital or outpatient surgery center, the nature of these practices provides ample opportunity for drug diversion. This less appreciated
form of drug diversion is associated with adverse
consequences, the scope of which is incalculable,
with harm to the drug diverter and others that is at
times horrific. There are no available data that precisely define the extent of drug diversion from the
health care facility workplace. However, it is well recognized that anesthesiologists, perhaps more than any
other class of physician, have ready access to highly
addictive psychotropic medications and have a higher
rate of addiction to opioid drugs than physicians in
other specialties.5 Furthermore, the drugs most commonly abused by anesthesiologists are obtained
through diversion.6 Such data suggest that ready access is a critical component of drug diversion from the
health care facility workplace.
The most common drugs diverted from the
health care facility setting are opioids. Although

Mayo Clin Proc. 䡲 July 2012;87(7):674-682 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.013 䡲 © 2012 Mayo Foundation for Medical Education and Research
www.mayoclinicproceedings.org

 DIVERSION OF DRUGS IN HEALTH CARE FACILITIES

other high-value drugs such as antiretroviral drugs,
athletic performance– enhancing drugs (eg, erythropoietin and anabolic steroids), and nonopioid psychotropic drugs have been diverted from the health
care facility workplace,7 the ensuing discussion focuses on the theft of controlled substances (CSs),
defined as medications classified as Schedules II (ie,
substances with high potential for abuse) through V
(ie, substances with lower potential for abuse than
substances in Schedules II, III, and IV), as defined by
the federal Drug Enforcement Administration
(DEA) and state statutes.8 We do not discuss the
topic of theft within the pharmacy setting, which is
largely accomplished by other means. Typically,
drugs stolen from health care facilities are used to
support an addiction of either the health care
worker (HCW) or an associate and, less commonly,
for sale for financial gain. This theft can be of unopened vials; vials or syringes that have been tampered with, resulting in either substituted or diluted
dosages being administered to the patient; or residual drug left in a syringe or vial after only a fraction
of the drug that has been signed out was actually
administered to the patient. In addition, this theft
can be of discarded syringes or ampules that have
been properly disposed of in a “sharps” safety
container.
In the outpatient setting, there is an elaborate
system of checks and balances for prescription, procurement, and dosing of a CS. However, in the
health care facility environment, vulnerability to diversion exists when a single provider, out of view of
others, is free to engage in drug procurement from
central stores, drug preparation, drug administration to patients, and/or disposal of drug waste.
Given that CSs are often titrated to a desired effect in
patients who may have widely varying drug requirements (eg, as a result of baseline individual variability, acquired habituation, or other factors), in the
absence of sufficient controls, it is relatively easy for
a single HCW, without the knowledge or collusion
of others, to divert drugs intended for patients. It is
beyond question that HCW diversion of opioids and
other CSs from the health care workplace has occurred since time immemorial.
Recent experience at Mayo Clinic and elsewhere
have revealed that such health care workplace drug
diversion creates numerous potential victims. Specifically, harm can come not only to drug diverters
but also to their patients and co-workers and to the
reputation of the health care institution that employs them. A recent devastating example is that of
an infected HCW in the Denver, Colorado, area
who, in the process of diverting narcotics for selfuse, passed on hepatitis C virus to approximately 36
patients.9 Such cases provide graphic examples of
why it is essential to reduce or eliminate opportuni-

ties for diversion of drugs in the health care facility
workplace.
Mayo Clinic has recently expanded its efforts to
better educate its staff about the risks of drug diversion and to enhance its methods for detection. With
encouragement from institutional physician-executives, we provide details of several instances that are
instructive in alerting others to the sub-rosa crimes
and harms that are likely occurring in health care
systems worldwide. In addition, we define the many
potential harms and victims associated with drug
diversion. We also review strategies that we have
developed, and that continue to evolve, in our efforts to combat diversion.

ILLUSTRATIVE VIGNETTES
There are many patterns of drug diversion in the
health care facility workplace environment, involving personnel from diverse backgrounds engaged in
diversions in a variety of practice locations. The heterogeneity of drug diversion practices is exemplified
in the following vignettes, all based on cases detected at Mayo Clinic medical centers during 2010
and 2011. These vignettes represent only a portion
of the instances of diversion that were detected during that time. For reasons of confidentiality, the vignettes have been slightly altered.
●

●

A visitor to the hospital asked to assist in bathing
a patient, who was a loved one. After the bath, the
patient’s nurse noticed that the time-released
patches used to transcutaneously administer the
potent opioid fentanyl were no longer attached to
the patient. An initial search of the patient’s room,
including a search of the trash cans, yielded nothing. When pressed, the visitor later “found” the
missing fentanyl patches in a previously searched
trash can.
A nurse working in a hospital unit discovered that
during her work shift she had misplaced her security key, which was required to refill and alter
the electronic programming of patient-controlled
analgesia (PCA) devices used to administer opioids to patients. Later in that same work shift, a
PCA pump on the same hospital unit was found to
have “malfunctioned” and delivered the entire syringe of the potent opioid hydromorphone to a
single patient over a relatively short time. However, it was astonishing that the patient exhibited
no evidence of narcotic overdose. Electronic analysis of the pump revealed that the PCA device had
been entered on several occasions, using a security key, and large amounts of opioid were administered during each trespass. On questioning, the
patient admitted to having found and hidden the
key and to having overridden the pump’s safety
lockout in order to self-administer large dosages

Mayo Clin Proc. 䡲 July 2012;87(7):674-682 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.013
www.mayoclinicproceedings.org

675

 MAYO CLINIC PROCEEDINGS

●

●

●

●

of opioid. It was only by virtue of this patient
being chronically habituated to opioids that a potentially fatal overdose was avoided.
A procedural sedation nurse assigned to administer opioids and sedatives to patients during
colonoscopy was found to have a secret pocket
sewn inside her uniform top, into which she
dropped syringes of the potent opioid fentanyl
and substituted them with syringes containing saline solution. During the colonoscopy, the nurse
would inject saline solution, rather than the prescribed fentanyl, into the patients and divert the
prescribed fentanyl for her own use.
A radiology technician who was positive for hepatitis C diverted unused fentanyl syringes intended for administration to patients in the interventional radiology area. It is believed that the
technician would remove the needle from a syringe, replace it with a smaller gauge needle for
self-injection, and then reattach the original needle to the syringe. The technician would then refill
the syringe with saline solution and return it to the
patient care area. In so doing, the technician infected 5 patients with hepatitis C virus.
Sharps waste containers (used to collect previously used syringes, needles, and vials) filled with
uncapped needles and used syringes were on multiple occasions found hidden in hospital areas
where they did not belong. Many containers had
clearly been broken into, and nearby were plastic
bags filled with unprotected used needles protruding from them. Video surveillance ultimately
led to discovery of an employee who was stealing
waste by transferring the contents of used sharps
containers into the bags and taking them home in
a search for discarded CSs. Video surveillance also
revealed this employee attempting to retrieve narcotics from an intact sharps container by sticking
her hand blindly into the container, resulting in
her hand being cut and bleeding from contact
with needles and glass.
A night custodian was discovered rummaging
through sharps waste containers holding nearly
empty vials of fentanyl. On questioning, the custodian revealed that he had been withdrawing and
consolidating the miniscule remaining fentanyl
from each vial, which he later self-injected to support his addiction.

POTENTIAL HARM ARISING FROM DRUG
DIVERSION
Addiction is sometimes viewed as a victimless crime.
When the addiction is supported by drug diversion
within the health care facility workplace environment, it becomes, in most situations, a multiplevictim crime in which patients, health care workers,
and employers can be harmed directly or indirectly.

676

Harm to the Patient
In cases of drug diversion, patients may potentially
receive substandard care from an addicted and
drug-diverting individual. If one assumes that the
patients required the drugs that were prescribed for
them, the absence of the drug entirely or dilution of
the drug such that they receive a dosage less than
that intended will likely result in the patient experiencing undue pain and/or anxiety, at least temporarily. This pain can be excruciating, as evidenced
by the recent diversion of fentanyl by a sedation
nurse in Minneapolis, Minnesota.10 While the patient was undergoing a surgical procedure, the nurse
took most of the prescribed dose of fentanyl for herself, leaving the patient “in agonizing pain.” Immediately before the procedure, this nurse allegedly
instructed the patient that he would have to “man
up” and tolerate some pain because he could not be
given much pain medication. This patient, a law
enforcement officer, was so distressed by the care he
received that he reported it to the police.10
In vignette 1, the harm was caused by a trusted
visitor who volunteered to bathe the patient in order
to steal the patient’s opioids. In vignette 2, the patient might easily have brought harm or death to
herself by overriding the safety mechanism built
into the PCA. In vignette 3, multiple patients likely
experienced pain as a consequence of insufficient
sedation and analgesia because they did not receive
the analgesia that was ordered for their procedures.
In vignette 4, 5 patients were infected with hepatitis
C, and in 1 of these, the infection contributed to the
patient’s death. Only in vignettes 5 and 6 was there
no clear patient harm, yet the reckless actions occurring in vignette 5 exposed many other innocent
HCWs, and possibly patients and visitors, to the
danger of a needle stick injury with all of the attendant infectious risks of bloodborne pathogens.
Other potential harm to patients includes the
possibility that they will receive an adulterated or
contaminated drug in place of the diverted drug,
such as the substitution of unsterile tap water for the
sterile drug that was intended for them, or an alternate drug to which they may be allergic. A contaminated drug could put patients at risk for bloodborne infections, sepsis, wound infections, and
infections of implanted foreign bodies such as prosthetic joints and heart valves.11,12
Furthermore, patients are at risk simply by virtue of being under the care of an addicted and potentially impaired HCW. The impairment may be as
obvious as the HCW being acutely intoxicated by a
drug or as subtle as the risk posed by a distracted
HCW whose primary focus is not patient care but
where, when, and how to obtain the next needed
dose of drug to stave off withdrawal symptoms. In
such a state, it is easy to imagine an HCW being

Mayo Clin Proc. 䡲 July 2012;87(7):674-682 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.013
www.mayoclinicproceedings.org

 DIVERSION OF DRUGS IN HEALTH CARE FACILITIES

susceptible to making cognitive patient-management or medication errors that might directly harm
the patient.
Potential Risks Addicted HCWs Pose to
Themselves
An individual who diverts drugs within the hospital
environment introduces a profound risk of morbidity and mortality to himself or herself. One need
look no further than the anesthesiology literature to
find numerous examples of presumably unintentional overdose and death associated with the diversion of drugs, typically highly potent sedative, opioid, and anesthetic agents.6,13 Death typically results
from severe respiratory depression or arrest, producing anoxic insults to the brain, heart, and other
organs. Death or anoxic brain injury to those who
otherwise survive the drug overdose are certainly
the most feared consequences; however, there are
many other important risks to the addicted HCW.
Among these are the risk of infection from unsterile
drugs and needles, unsanitary injection techniques,
or blood-to-blood transmission of pathogens from a
patient to an HCW.
In addition to the biologic risks, drug diversion
is associated with profound professional risks for
HCWs. Stealing CSs from the supply chain exposes
them to felony criminal prosecution and civil malpractice actions, as well as actions against their professional licenses. Other potential professional hazards include the risk of prosecution for fraudulent
charting if they chart that the patient received medication that they know they did not give and the
attendant risk of prosecution for billing fraud resulting from submitting charges to the patient or insurance provider for drugs and services they know the
patient did not receive.
Potential Risk to Other HCWs
Vignette 5 graphically demonstrates a potential
source of risk to other HCWs from the irresponsible
actions of an HCW who was diverting drugs. Unexpectedly finding uncapped contaminated needles
and broken glass vials in areas where they should
not be puts fellow HCWs at risk for mechanical injury and infection by bloodborne pathogens. In addition, although co-workers may be unaware of the
colleague’s impairment, shared patient-care responsibilities might result in adverse patient outcomes,
thereby placing all members of the care team at risk
for medicolegal liability.
Many addicted HCWs become masters at manipulating both the drug control systems in the areas
where they work and at manipulating their colleagues so that the addict can divert drugs undetected. Often this involves breaches of policies and

procedures on the part of the addicted HCW’s colleagues, whereby they unwittingly aid their addicted
colleague by “witnessing” the disposal of leftover
CSs that they did not witness. This puts the otherwise innocent HCW at risk of disciplinary action for
being found in violation of such routine policies and
procedures.
Potential Risk to Employer
Health care workers who divert CSs from the workplace introduce potential risk to their employer.
Harms include the loss of revenue from diverted
drugs and the potentially poor work quality or absenteeism of the addicted HCW. Drug-diverting
HCWs also place their employer at risk of civil liability for failure to prevent, recognize, or address
signs of drug diversion or of an impaired or addicted
employee. Should harm befall a patient while under
the care of an addicted HCW, both the HCW and
the employer are vulnerable to civil litigation.
When there is suspected diversion of CSs in the
workplace, the employer typically invests considerable resources to conduct investigations and forensic testing required to confirm or refute diversion.
The objectives are to halt any ongoing or future
harm from a drug-diverting HCW and to assess any
past harm to patients, the care environment, and
other vulnerable areas. The exhaustive nature of
these investigations has been effectively reported by
Thompson et al,14 who described early efforts to
unravel the cases of unexplained hepatitis C in vignette 4. That the investigations in vignette 4 did not
end with the activities described in the report by
Thompson et al is astounding. Other critical events
were discovered subsequent to that report, and the
source of the transmission was ultimately confirmed
(ie, more than 1 year after the publication by
Thompson et al, during which time 3 additional patients were infected by the diverting HCW).15 The
sense that the illicit activities by this HCW could
have possibly harmed scores of patients resulted in a
massive “look back” evaluation of the practices and
timelines involving the suspected HCW. Free testing was offered to nearly 4,000 patients who were
believed to have possibly been at risk of exposure.
As a result of these tests, 5 patients were ultimately
proved to have the same genetic subtype of hepatitis
C as the infected HCW, presumably because the
infections emanated from a common source.
Investigations such as this are expensive in
terms of human and nonhuman resources, time,
and finances; however, they are a necessary part of
health care systems acting responsibly. Such efforts
first and foremost fulfill an ethical obligation to past,
present, and future patients. They also are a critical
component of long-term risk management for the
employer.

Mayo Clin Proc. 䡲 July 2012;87(7):674-682 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.013
www.mayoclinicproceedings.org

677

 MAYO CLINIC PROCEEDINGS

Mandatory reporting requirements may cause
diversion incidents to become public knowledge
and potentially highly publicized in the media. In
the long term, this can have a devastating effect on
the morale of the employees of the health care institution. It also can have an even more profound effect
on the patients and their families who have entrusted their care to the institution, whether or not
they were directly affected by an episode of drug
diversion. Disappointed or mistrustful patients may
seek medical care elsewhere, resulting in financial
losses to the institution that, in turn, harm its ability
to sustain a mission of providing high-quality patient-centered care.
Because of these cumulative risks, it is essential
that all health care institutions establish surveillance
programs in an effort to detect potential diversion of
CSs and implement mechanisms, policies, and procedures that enable quick intervention when diversion is identified, ideally before harm to patients and
HCWs can ensue. This is true not only because it is
an ethical imperative but also because it is the most
fiscally responsible plan for the survival and prosperity of the mission of the health care institution.
GENERAL CONCEPTS OF PREVENTION AND
DETECTION
Many HCWs are unaware that drug diversion is a
serious problem in the workplace. Thus, broadbased educational efforts must be instituted that focus on the nature and scope of the problem, signs
and symptoms of possible diversion and addiction,
and proper ways to respond if diversion is suspected. The entire workforce, not only those with
ready access to CSs, should be informed of the
threats to life and career presented by drug diversion. Orientation of new employees should include
such education, and ongoing education should occur throughout an HCW’s career. In an effort to
discourage diversion, all employees should be made
aware that procedures are in place to facilitate detection, with the objective of preventing patient
harm, diversion-related addictive illness, and drugrelated deaths. Employees also should be taught
how to access available resources if they suspect diversion is occurring. A Web-based teaching module
on the topic of diversion is currently being created at
Mayo Clinic to facilitate these educational goals,
with consideration being given to making the satisfactory completion of this module a required part of
annual employee competency assessments.
The ideal drug-diversion and prevention program is highly sophisticated, drawing from the
knowledge bases of behavioral and biologic sciences, information technology, law enforcement,
pharmacy sciences, credentialing and licensure experts, and industry loss-prevention sciences. There

678

is tremendous diversity among the prevention and
detection efforts of various medical centers, ranging
from haphazard reactionary programs to highly sophisticated proactive programs. This is an evolving
field, and even the best efforts have not yet achieved
the ideal situation in which the numbers of drug
diversions and their harmful consequences approach zero. Mayo Clinic has, for the past several
years, been developing and fine-tuning a uniform
response to suspected diversion. The following is a
brief timeline of the evolution of such diversion prevention efforts by Mayo Clinic.
OPERATIONALIZATION OF DRUG DIVERSION
PREVENTION AND DETECTION EFFORTS AT
MAYO CLINIC
Department of Anesthesiology
Anesthesiologists and nurse anesthetists are health
care providers in whom psychotropic drug use
and addiction is considered an occupational hazard.6,13,16 Mayo Clinic is no exception in this regard; thus, it is not surprising that concerted efforts
to detect drug diversion began in the Department of
Anesthesiology. Detection has often been precipitated by personnel underperformance or behavioral
changes at work, frequent unexplained work absences, patients who seem to be undermedicated in
the period after surgery despite documentation of
administration of seemingly adequate narcotic dosages, and, rarely, HCW death related to a CS.
In the early 1990s, in response to several episodes of fentanyl diversion from anesthesia supplies in the operating room (OR) environment, an
improvement in CS handling was sought. After a
review of procedures used by multiple health care
institutions was conducted by members of the departments of anesthesiology and pharmacy, departmental leadership decided to purchase automated
distribution machines (ADMs) for the OR environment. Secure return bins were also installed so that
all unused portions of CS doses could be submitted
for subsequent random quantitative drug assays before destruction of the CS. In addition, close cooperation between the departments of anesthesiology
and pharmacy created a system whereby returned
waste volumes were reconciled with ADM dispensing records and patient anesthesia records, and any
discrepancies were aggressively investigated until
resolved. Since initiation of these improved control
systems, there has been a dramatic decrease in the
frequency of CS diversions (unpublished data, Keith
Berge, MD, Department of Anesthesiology, Mayo
Clinic, June 7, 2012). Frequent educational sessions
about the risk of addiction and diversion by Department of Anesthesiology personnel were also undertaken for all workers in the OR environment, not

Mayo Clin Proc. 䡲 July 2012;87(7):674-682 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.013
www.mayoclinicproceedings.org

 DIVERSION OF DRUGS IN HEALTH CARE FACILITIES

only anesthesia personnel but also surgical nurses
and surgical technicians, among others. In these sessions, the signs and symptoms of drug diversion and
use, as we have previously described,15 are discussed in an effort to promote rapid identification of
aberrant behavior.

Institution-Wide Reforms at Mayo Clinic
Mayo Clinic is a large and complex organization
with 55,000 employees in multiple states. After several diversion incidents in multiple Mayo Clinic facilities, a unified policy has been evolving to combat
the problem. As part of this effort, a new position
called the Medication Diversion Prevention Coordinator (MDPC) was created within the Department of
Pharmacy in the larger facilities. This role calls for an
individual familiar with the CS supply chain and
management policies who is, therefore, able to assess areas of vulnerability for potential diversion.
This individual must also be skilled in the use of
systems available for tracking, trending, and evaluating the dispensing patterns of health care professionals and be willing to participate in educational
efforts about the dangers of, and recognition of,
drug diversion.
With input from multiple participants, a “best
practices” list was created that identified 77 specific
points that, were all the points implemented, would
create what we believe to be the best possible system
to date to prevent CS diversion (Supplemental
Table, available online at http://www.mayoclinicproceedings.org). Inasmuch as all of the most recently discovered diversion episodes were occurring
outside of the tightly controlled OR environment,
OR control systems were expanded to enable similar
controls in other areas with high CS use. Thus, the
ADM/waste retrieval system has been implemented
in the Emergency Department and the gastrointestinal endoscopy suite at Mayo Clinic in Rochester. In
time, it will also be used in the intensive care unit
and other nursing units with high CS use. Educational efforts have been increased to publicize the
Medication Diversion Prevention Committee and
the active surveillance efforts it brings to the problem. Although institution-wide uniformity in the
approach to diversion prevention efforts is the desired goal, at this time, various entities within the
Mayo Clinic system are at different points along the
continuum of developing and introducing this uniform approach. The ultimate goal is for an MDPC or
designee to be available via pager at all times to respond to and rapidly investigate potential diversions, with the number for this pager prominently
displayed on every ADM. Some Mayo Clinic sites
currently rely on a compliance hotline to service this
notification role.

As further best practices are identified, they are
distributed to all Mayo Clinic facilities. In addition,
details of each incident of confirmed diversion are
shared among the MDPCs at each site in an effort to
gain insights into and address any potential areas of
vulnerability. Efforts are under way to align policies
and procedures across all Mayo Clinic facilities for
response to suspected drug diversions. Uniform
policies will provide a consistent approach to confirming that a diversion has occurred, notifying the
appropriate institutional leaders and other parties
with a need to know, altering employment status of
the drug-diverting personnel, and ensuring that
mandatory reporting requirements are met (eg, to
governmental agencies). Although some of these efforts are still evolving, many of these policies are
now in the final stages of implementation. All policies adhere to core principles but are tailored to both
the requirements of the individual health care site
and the laws of the state in which each affected Mayo
Clinic site is located.
Organizational Features of Institution-Wide Mayo
Clinic Effort
At the larger Mayo Clinic facilities, teams have been
created to investigate suspected diversion episodes.
These multidisciplinary teams, all subgroups of the
Medication Diversion Prevention Committees, are
called the drug diversion response teams (DDiRT).
Each team consists of the MDPC, the Director of
Pharmacy, a member of the Department of Safety
and Security, and a physician chair of the Medication Diversion Prevention Committee. Other departments represented include human resources, legal, nursing, and administration. The Rochesterbased team currently assists with investigation in the
Mayo Clinic Health System sites near Mayo Clinic
Rochester, although some of the larger sites are in
the process of creating their own on-site DDiRTs.
When diversion is suspected, any Mayo Clinic
employee can initiate the chain of events that results
in a thorough investigation. The Figure provides a
flowchart of how these investigations proceed, starting with the diversion either suspected as a result of
aberrancies identified through routine surveillance
of prescribing patterns or by a witnessed event. If
there is concern that the diversion might involve an
acutely impaired or intoxicated HCW, his or her
supervisor is engaged and the HCW is immediately,
but discreetly, removed from patient care duties and
escorted to a new location (eg, Employee Health
Services) for further evaluation including a “for
cause” drug test. However, such drug testing can
neither conclusively confirm nor conclusively rule
out all forms of CS diversion or HCW self-administration. If the test result is negative, it does not eliminate the possibility that the drug was being diverted

Mayo Clin Proc. 䡲 July 2012;87(7):674-682 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.013
www.mayoclinicproceedings.org

679

 MAYO CLINIC PROCEEDINGS

Medication diversion
is suspected

Surveillance data
suggest diversion

Employee
appears impaired
or drug use
witnessed?

Contact employee supervisor, who
• Notifies appropriate manager
• Retains any evidence
• Notifies diversion team pager
• Notifies HR service representative

Yes

No
Supervisor takes
immediate necessary
action and calls
diversion team pager

Employee taken to EOHS
for evaluation

MDPC notified
Results reported to
supervisor, MDPC, and HR
MDPC notifies
DDiRT chair, DOP,
security
representative

Further analysis of
data

Preliminary
investigation
completed
by MDPC

Employee’s
supervisor’s input

No

Outcome may
differ for
alcohol vs drug
findings

Drug test
positive?

Yes
No

Suspicion
exists or
confirmed?
Yes
MDPC convenes DDiRT

DDiRT reviews evidence and
determines next steps:
• Interview employee
• EOHS/treatment
• Further investigation needed
• Internal reporting
• External reporting

MDPC coordinates
recommendations

Diversion
confirmed or
employee action to
be taken

No

DDiRT consulted
and/or
further monitoring

Yes
Final actions provided to MDPC

MDPC documents investigation
results in database

Findings forwarded to HR,
employee manager, and EOHS to
determine employee action plan

MDPC confirms
reporting completed

FIGURE. Medication diversion response flowchart. DDiRT ⫽ Drug Diversion Response Team; DOP ⫽ Director of Pharmacy; EOHS ⫽
Employee and Occupational Health Services; HR ⫽ Department of Human Resources; MDPC ⫽ Medication Diversion Prevention
Coordinator.

680

Mayo Clin Proc. 䡲 July 2012;87(7):674-682 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.013
www.mayoclinicproceedings.org

 DIVERSION OF DRUGS IN HEALTH CARE FACILITIES

for use by another. If the test is positive, it does not
eliminate the possibility that the individual under
suspicion for diversion might in addition have a legitimate prescription for and use of the drug allegedly diverted. In any event, the MDPC (or designee)
is promptly contacted via pager.
In the absence of obvious employee impairment, the MDPC will ask the supervisor to secure
any evidence that might be inadvertently destroyed
but not to initiate an investigation and to refrain
from questioning the employee about the event. If
possible, the MDPC notifies the chair of the local
DDiRT and the Director of Pharmacy and promptly
initiates a preliminary investigation consisting of review of the documentary records and a discussion
with the immediate supervisor in the area of the
suspected diversion. If this inquiry reveals no evidence of diversion, the case is closed and logged into
the database. Should the investigation reveal cause
for ongoing concern, the MDPC convenes the
DDiRT within 24 hours to determine the optimal
course of action. This may involve further surveillance, an employee interview by the MDPC and the
DDiRT Department of Security representative, forcause drug testing, consideration of enlisting the assistance of law enforcement agencies (eg, local law
enforcement, the DEA, and the US Food and Drug
Administration), or other approaches deemed appropriate by the group. As the investigation proceeds, each DDiRT meeting gives consideration to
the most appropriate time for reporting on the presence or progress of the investigation to senior institutional leadership.
The investigation ends when enough proof is
gathered to determine that a diversion has or has not
occurred. If it is determined that there was no diversion, the case is closed. If, however, a diversion has
been found, the case is turned over to the Department of Human Resources to determine what action
will be taken insofar as the employment status of the
drug diverter. At this point, the role of the DDiRT is
complete but for the MDPC entering the details into
the database and making certain that all mandatory
internal and external reporting (eg, to the DEA, the
state Pharmacy Board, and local law enforcement)
has been accomplished. Then, details of the drug
diversion incident are shared among MDPCs in an
effort to identify and remedy areas of shared vulnerability for future diversions.
Prompt actions are of utmost importance throughout these deliberations, both to remove those guilty
of drug diversion from the patient care environment
and to avert harming the well-being of HCWs who
are innocent. In actual practice, we estimate that
approximately 75% of suspected diversion investigations at the Rochester Mayo Clinic location have
been brought to closure by a confession on the part

of the drug diverter (personal communication,
Karen Sikkink, CPhT, Mayo Clinic Rochester
MDPC, August 26, 2011).
CONCLUSION
Diversion of drugs from legitimate to illicit use is
being recognized with increasing frequency in the
United States. Although the full extent of diversion
from health care facilities is unknown and probably
unknowable, our experience makes clear that it is
a considerable and ongoing problem. Addicted
HCWs who are diverting drugs from the health care
facility workplace pose a risk to their patients, their
employers, their co-workers, and themselves. It is
essential that all health care institutions have a
robust system in place to identify and investigate
suspected diversion as rapidly and efficiently as possible and that they implement policies and procedures that enable a standardized and effective response to confirmed diversion.
Drug diversion by HCWs violates the core value
that the needs of the patient come first. Clearly, if we
are to optimize our approach to inpatient drug diversion and its consequences, we must look at such
diversion not as a victimless act but as a multiplevictim crime.
SUPPLEMENTAL ONLINE MATERIAL
Supplemental material can be found online at
http://www.mayoclinicproceedings.org.
Abbreviations and Acronyms: ADM ⴝ automated distribution machine; CS ⴝ controlled substance; DEA ⴝ Drug
Enforcement Administration; DDiRT ⴝ drug diversion response team; HCW ⴝ health care worker; MDPC ⴝ medication diversion prevention coordinator; OR ⴝ operating
room; PCA ⴝ patient-controlled analgesia
Correspondence: Address to Keith H. Berge, MD, Department of Anesthesiology, Mayo Clinic, 200 First St SW,
Rochester, MN 55905 (berge.keith@mayo.edu).

REFERENCES
1.

2.

3.

4.

5.

Drug Abuse Prevention and Control. 21 USC Chapter 13
(2011). http://uscode.house.gov/download/pls/21C13.txt. Accessed March 19, 2012.
National Association of Drug Diversion Investigators
(NADDI) Web site. http://naddi.associationdatabase.com/
aws/NADDI/pt/sp/Home_Page. Accessed March 19, 2012.
U.S. Prescription Drug Sales Grow Slowly; Hydrocodone Most
Prescribed. Seeking Alpha Web site. Published March 26, 2009.
http://seekingalpha.com/article/128003-u-s-prescription-drug-salesgrow-slowly-hydrocodone-most-prescribed. Accessed March 19,
2012.
National Institute on Drug Abuse (NIDA). Prescription medications: brief description. NIDA Web site. http://www.nida.nih.
gov/drugpages/prescription.html. Accessed March 19, 2012.
Alexander BH, Checkoway H, Nagahama BA, Domino KB.
Cause-specific mortality risks of anesthesiologists. Anesthesiology. 2000;93(4):922-930.

Mayo Clin Proc. 䡲 July 2012;87(7):674-682 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.013
www.mayoclinicproceedings.org

681

 MAYO CLINIC PROCEEDINGS

6. Bryson EO, Silverstein JH. Addiction and substance abuse in
anesthesiology. Anesthesiology. 2008;109(5):905-917.
7. Inciardi JA, Surratt HL, Kurtz SP, Cicero TJ. Mechanisms of
prescription drug diversion among drug-involved club- and
street-based populations. Pain Med. 2007;8(2):171-183.
8. US Department of Justice; Drug Enforcement Administration
(DEA), Office of Diversion Control. Information and legal resources. http://www.deadiversion.usdoj.gov/schedules/index.html.
Accessed March 19, 2012.
9.

AP Daily News Staff Writer. Heroin-addicted technician Kristen Diane Parker infected 3 dozen with hepatitis C. New York
Daily News. January 18, 2010. http://articles.nydailynews.com/
2010-01-18/news/17945085_1_kristen-diane-parker-heroinaddiction-infected. Accessed March 19, 2012.

10. Van Denburg H. Larry V. King, Dakota County Deputy, was
Sarah May Casareto’s O.R. – bound victim. CITYPAGES Blogs.
February 11, 2011. http://blogs.citypages.com/blotter/2011/
02/larry_v_king_sarah_may_casareto_victim.php. Accessed
March 19, 2012.

682

11. Maki DG, Klein BS, McCormick RD, et al. Nosocomial Pseudomonas pickettii bacteremias traced to narcotic tampering: a
case for selective drug screening of health care personnel.
JAMA. 1991;265(8):981-986.
12. Ostrowsky BE, Whitener C, Bredenberg HK, et al. Serratia
marcescens bacteremia traced to an infused narcotic. N Engl
J Med. 2002;346(20):1529-1537.
13. Berge KH, Seppala MD, Lanier WL. The anesthesiology communities approach to opioid- and anesthetic-abusing personnel: time
to change course. Anesthesiology. 2008;109(5):762-764.
14. Thompson ND, Hellinger WC, Kay RS, et al. Healthcareassociated hepatitis C virus transmission among patients in
an abdominal organ transplant center [published online
ahead of print May 26, 2009]. Transpl Infect Dis. 2009;11(4):
324-329.
15. Hellinger WC, Bacalis LP, Kay RS, et al. Health care-associated
hepatitis C virus infections attributed to narcotic diversion. Ann
Intern Med. 2012, 156:477-482.
16. Berge KH, Seppala MD, Schipper AM. Chemical dependency
and the physician. Mayo Clin Proc. 2009;84(7):625-631.

Mayo Clin Proc. 䡲 July 2012;87(7):674-682 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.013
www.mayoclinicproceedings.org