The impact is clear when looking at recent real-word examples. In Oregon, a nurse allegedly infected more than 40 patients by replacing their liquid fentanyl with tap water to steal the medication. In a separate incident, a nurse in Washington was found to have taken hydromorphone for personal use, leading the hospital to pay a $15,000 penalty and implement corrective measures to prevent future instances. These events highlight the importance of drug diversion policy and procedure, and how the reputational, regulatory, and, most importantly, patient safety risks that health systems face when diversion goes unchecked.
To strengthen earlier detection and monitoring, forward-thinking health systems are leveraging artificial intelligence (AI) and machine learning to identify concerning patterns that might otherwise go unnoticed, from subtle spikes in medication dispensing or utilization to unusual access behaviors. But technology, while powerful, is only one part of the puzzle. Continuously updating and thoughtfully integrating policy and procedure training, as well as supporting a culture of accountability, is the key to stronger, more effective drug diversion programs within your health system.
Common barriers to effective drug diversion prevention policy
In recent years, hospitals have made increased investment in personnel and training to tackle drug diversion head-on. Yet, even with these increased efforts, four out of five (81%) healthcare leaders still believe drug diversion occurs within their organizations, with many of these incidents likely remaining unreported.
Understanding why diversion remains a challenge requires looking at the common barriers that prevent program policies from being fully effective. The AHA’s 2025 workforce snapshot shows that the U.S. healthcare workforce continues to fall short of meeting demand. Limited staffing and resources can make it challenging to put policies into practice on the hospital floor. These persistent staffing gaps place additional strain on hospitals, especially smaller and more rural facilities with fewer dedication drug diversion prevention staff.
Adequate representation of key departments in training efforts is another barrier. While program leads largely agree on the critical nature of buy-in and engagement from cross-disciplinary departments, only about one third of programs currently involve anesthesiology, and only 20% involve HR. Excluding these key departments from the conversation can create training gaps and overlook perspectives critical to improving detection and prevention.
Sustained progress in drug diversion prevention also relies heavily on active leadership engagement to prioritize ongoing education and address cultural challenges. Staff may hesitate to report suspected diversion when the process feels punitive or unsupportive, highlighting the need for a culture that balances accountability with empathy. Leaders set the tone by modeling best practices, emphasizing shared responsibility, and framing diversion like other health challenges: by providing support, guidance, and resources to move forward. This approach creates an environment where staff feel empowered to act and to learn.
The role of policy in drug diversion programs
Effective drug diversion policy and procedure relies on the integration of both external regulations, such as compliance with the Drug Enforcement Administration (DEA), and standardized internal best practices. While external policies help mitigate consequences like financial penalties or reputational risk, internal standards are equally essential for ensuring safe, consistent practices and supporting a hospital’s overall success.
The most effective policies:
- Ensure compliance with federal and state regulations, keeping hospitals legally sound while supporting daily operations.
- Provide clear definitions of diversion, along with guidance on identifying patterns and reporting concerns.
- Include well-defined investigation protocols that outline delegated responsibilities and next steps. For example, providing a clear list of do's and don'ts for interviews can help ensure your health system is thoroughly prepared for different outcomes during the investigative process.
When reviewing the success of implemented policies, program leaders should ask: Are they actionable, accessible, and regularly updated? Policies that meet these standards enable organizations to remain proactive and address potential challenges before they escalate.
Successfully turning drug diversion policy and procedure into practice
However, policies alone do not stop drug diversion, no matter how well-crafted. To be truly effective, staff must understand how to apply and follow them in daily practice. Consistent training helps employees recognize warning signs, respond appropriately, and ultimately builds confidence in prevention programs, reinforcing a culture of accountability.
To make policy and procedure training more effective and easier to follow, consider these practical steps:
- Centralize policies in an easy-to-access format, such as digital platforms.
- Leverage modular training that staff can complete in short sessions, rather than lengthy one-time trainings.
- Incorporate technology training to teach staff how to use diversion detection tools effectively.
- Schedule consistent refreshers and compliance checks to keep everyone aligned.
- Measure and adapt by tracking engagement and updating training when policies change.
Integrating diversion policies into onboarding and role-specific training—particularly for pharmacy, nursing, and other high-risk departments—is key. Regular refreshers, enhanced with real-world scenarios or simulations, also give staff a chance to practice responding to potential diversion in a safe environment.
These are steps Shealee Mitchell, Jur., BSN, RN, embraced when she stepped into the role of Drug Diversion Prevention Manager. Inheriting a program, Mitchell focused on rebuilding clear and robust policies that worked for everyone, from pharmacy to nursing to security. That meant actively listening to staff concerns, incorporating feedback, and ensuring alignment with leadership. This inclusive approach created stronger buy-in and helped keep drug diversion prevention and monitoring top of mind across the organization.
When rebuilding the program, Mitchell also prioritized technology as a powerful tool to translate policies into effective practice. By leveraging Sentri7® Drug Diversion alongside training and ongoing monitoring, the organization is able to catch errors earlier, preventing escalation.
