Hospital Drug Diversion Checklist

Governance & Program Oversight 0 / 7

Designated Diversion Prevention Officer/Coordinator with defined authority (w:3)

Interdisciplinary diversion prevention committee meets quarterly (or more frequently) (w:3)

Written diversion prevention policy approved by governing board (w:3)

Policy addresses all controlled substance categories (II-V) and all departments (w:2)

Annual program effectiveness review with documented improvements (w:3)

Executive leadership receives regular diversion metrics dashboard (w:2)

Non-punitive reporting culture policy documented and communicated (w:3)

Controlled Substance Lifecycle Management 0 / 9

Automated dispensing cabinets (ADC) in all controlled substance storage areas (w:3)

Two-person verification for ADC restocking and narcotic waste (w:2)

Barcode scanning at administration for all controlled substances (w:3)

Real-time discrepancy detection and alerting on ADC transactions (w:3)

Waste and partial dose documentation with witness verification (w:2)

Controlled substance returns reconciled within 72 hours (w:2)

Sterile compounding areas have separate controlled substance logs (w:2)

Controlled substance delivery from pharmacy to floor uses tamper-evident packaging (w:1)

Sample medications tracked with same rigor as dispensed inventory (w:2)

Perioperative & Procedural Areas 0 / 6

Anesthesia cart controlled substances locked and inventoried between cases (w:3)

Waste anesthesia controlled substances witnessed and documented per case (w:3)

ADC or equivalent controlled substance storage inside OR suite (w:2)

Controlled substance reconciliation from pharmacy to case to waste (closed-loop) (w:3)

Automated surveillance for anesthesia provider patterns (waste rates, case counts) (w:2)

Kit checkout and return logs reconciled within 24 hours (w:2)

Data Analytics & Surveillance 0 / 9

Automated surveillance system (e.g., NarxCare, dispense cabinet analytics software, or equivalent) (w:3)

Regular review of ADR (admin discrepancy report) patterns by unit and shift (w:2)

Controlled substance usage benchmarking — outlier detection by practitioner (w:3)

Waste rate analysis — practitioners with abnormally high waste flagged (w:3)

Wasted medication reconciliation rate (wasted vs. documented) (w:2)

After-hours controlled substance dispensing reviewed for unusual patterns (w:2)

Patient-controlled analgesia (PCA) discrepancy monitoring (w:2)

Controlled substance overrides tracked and reviewed monthly (w:2)

DEA 106 reports tracked and trended over time (w:1)

Personnel & Access Controls 0 / 8

Pre-employment criminal background check for all employees with CS access (w:2)

Pre-employment drug screening with expanded panel (w:2)

Controlled substance access removed immediately on termination/resignation (w:3)

Role-based ADC access — no shared logins or badges (w:2)

Periodic access audit — all ADC users reviewed quarterly (w:2)

Fit-for-duty policy addressing fatigue, impairment, and behavioral concerns (w:2)

New hire controlled substance diversion awareness training (w:1)

Annual diversion prevention competency/training for all CS-touching staff (w:2)

Physical Security 0 / 7

All controlled substance storage areas have restricted access (card/bio + PIN) (w:3)

Closed-circuit cameras in pharmacy and all ADC storage areas (w:2)

Breakaway/emergency override of ADC triggers distinct audit trail (w:2)

Controlled substance waste receptacles secured and monitored (w:1)

Off-hour access to pharmacy logged and reviewed daily (w:3)

Security video retention ≥ 90 days for CS storage areas (w:1)

Controlled substance destruction witnessed and documented per DEA requirements (w:3)

Incident Reporting & Investigation 0 / 9

Clear low-threshold mechanism for reporting suspicious behavior or discrepancies (w:3)

Documented investigation protocol with defined timelines (w:2)

Standardized investigation report template used consistently (w:2)

DEA Form 106 filed within 1 business day of significant loss determination (w:3)

Root cause analysis performed for confirmed diversion events (w:2)

Corrective action tracking with closure verification (w:2)

Peer support / recovery pathway offered to affected practitioners (w:1)

State licensing board notified as required by law (w:3)

Post-incident program control gap analysis completed (w:2)

Regulatory Compliance 0 / 8

DEA registration current and accurate for all sites (w:3)

State controlled substance registration current (where applicable) (w:3)

DEA biennial inventory completed on schedule (w:2)

Controlled Substance Ordering System (CSOS) certificates current (w:2)

Red flags from DEA Self-Assessment checklist addressed (w:2)

Joint Commission controlled substance standards reviewed and current (w:2)

State-specific controlled substance reporting requirements met (e.g., PMP) (w:2)

Reverse distributor agreements current and destruction logs complete (w:1)

Assessment Summary

Overall Score

Governance & Program Oversight 0%

Controlled Substance Lifecycle Management 0%

Perioperative & Procedural Areas 0%

Data Analytics & Surveillance 0%

Personnel & Access Controls 0%

Physical Security 0%

Incident Reporting & Investigation 0%

Regulatory Compliance 0%

Select items above to see your score.

Program Assessment Checklist

Assessment Summary