Diversion Risk Assessment by Unit

Every clinical unit has a different drug profile, workflow, and vulnerability. Tailored monitoring strategies by care area.

HIGH
Emergency Department
Highest Risk Drugs
  • Fentanyl (IV push)
  • Versed / Midazolam
  • Ketamine
  • Hydromorphone (Dilaudid)
  • Morphine
  • Propofol (procedural)
Common Diversion Methods
  • Waste falsification — charting partial dose, keeping the rest
  • Over-riding for "pain emergency" without order
  • Diverting from multidose vials (ketamine, versed)
  • Narcotic waste from trauma activations (unwitnessed)
Monitoring Strategy
  • Override rate by practitioner — ED overrides are common but outliers matter
  • Multidose vial yield — count doses per vial vs. expected
  • Night shift waste patterns — less oversight after 2300
  • Waste witness rate — % of waste events with valid witness
Red Flags
  • Same nurse always managing the highest-acuity patients
  • Frequent trauma assignments and consistently high waste
  • Patients reporting pain despite charted fentanyl administration
  • Nurse who stays late to "finish charting" alone
HIGH
Intensive Care Unit
Highest Risk Drugs
  • Propofol (large volume infusion)
  • Fentanyl (drip and IV push)
  • Versed / Midazolam
  • Dexmedetomidine (Precedex)
  • Hydromorphone PCA
  • Ketamine (continuous infusion)
Common Diversion Methods
  • Syringe swap — replacing full syringes with saline
  • Diverting from multidose vials (propofol, insulin, heparin)
  • PCA tampering — accessing reservoir or Y-site
  • Over-reporting waste on drip changes
Monitoring Strategy
  • Dispense vs. pump-log reconciliation for drips
  • Propofol vial usage per patient — count vials opened vs. documented
  • PCA waste volume vs. expected residual
  • Infusion pump log audits — look for programming changes, restarts, pauses
Red Flags
  • High waste rates on propofol and fentanyl drips
  • Frequent PCA cassette changes with high residual
  • Syringe swaps that coincide with colleague breaks
  • Sedated patients who appear more alert than expected
ELEVATED
Operating Room / PACU
Highest Risk Drugs
  • Propofol (induction/maintenance)
  • Fentanyl / Sufentanil
  • Midazolam
  • Succinylcholine / Rocuronium
  • Ketamine
  • Hydromorphone (PACU)
Common Diversion Methods
  • Unwitnessed waste between cases
  • Anesthesia cart tampering during off-hours
  • Propofol vial diversion — drawing from multiple vials without documentation
  • Pharmacy kit checkout / return discrepancies
  • Fish eye / wide-angle cameras needed to cover moving anesthesia carts
Monitoring Strategy
  • Anesthesia provider waste rate — per-case and per-drug
  • Kit checkout → return reconciliation
  • Case-level CS usage vs. expected based on procedure type
  • After-hours OR access logs
  • Camera footage — fish eye lens with privacy masking of surgical field
Red Flags
  • Provider with consistently higher waste than peers for same procedure
  • Missing or incomplete kit returns
  • Anesthesia cart left unlocked or unattended
  • Provider who frequently does add-on/emergency cases alone
MODERATE
Med-Surg / Telemetry
Highest Risk Drugs
  • Oral opioids (oxycodone, morphine)
  • Fentanyl patches
  • PCA hydromorphone
  • Hydromorphone IV push
  • Diphenhydramine IV (non-controlled but diverted)
Common Diversion Methods
  • Pocketing oral opioids — charting administered that were thrown away
  • Fentanyl patch theft — charting placement but keeping the patch
  • PCA tampering
  • Waste falsification on IV push narcotics
Monitoring Strategy
  • Oral opioid dispense vs. administration matching
  • Fentanyl patch removal documentation audit
  • PCA pump log vs. MAR reconciliation
  • Waste documentation completeness by nurse
Red Flags
  • Patients reporting pain despite opioid charting
  • Fentanyl patch found loose in linen/bedding
  • Same nurse has multiple patients with "uncontrolled pain"
  • Frequent PRN opioid administration without pain score change
SPECIALTY
Oncology
Highest Risk Drugs
  • Hydromorphone (IV and oral)
  • Morphine (IV and oral)
  • Fentanyl (IV and patches)
  • Oxycodone (oral)
  • Hospital-only oral opioids (infusion center formulas)
  • Non-CS: diphenhydramine, ondansetron
Common Diversion Methods
  • Patient-administered pump tampering (ambulatory infusion pumps)
  • Oral opioid pocketing — large volumes dispensed to unit
  • Returned medication theft — patient discharged, meds not returned
  • Waste from patient-specific batches
Monitoring Strategy
  • Patient pump return reconciliation — volume dispensed vs. returned vs. documented
  • Unit-dose CS return tracking
  • Oral opioid dispense-to-admin matching by shift
  • Infusion center CS inventory — perpetual vs. physical
Red Flags
  • High oral opioid returns — large numbers of "patient refused" doses
  • Patient pump returns with less volume than expected
  • Frequent breakthrough pain requiring IV push in infusion center
HIGH
Pharmacy
Highest Risk Drugs
  • Every controlled substance in the facility
  • Bulk narcotic solutions
  • Concentrated opioids for compounding
  • Returned medications awaiting destruction
Common Diversion Methods
  • ADC restocking diversion — pocketing during cart fill
  • Inventory adjustment falsification
  • Bulk compounding discrepancies
  • Return processing diversion — pocketing returned CS, documenting destruction
  • Unsupervised destruction — signing off waste that didn't occur
Monitoring Strategy
  • ADC restocking variance — expected vs. actual for each technician
  • Bulk compounding yield — units produced vs. raw drug used
  • Inventory adjustment report — every CS adjustment with justification
  • Return destruction log — witness verification for every destruction
  • Camera coverage of compounding and restocking areas
Red Flags
  • Same technician always restocking high-value CS cabinets
  • Frequent "counting error" inventory adjustments
  • Bulk compounding yields consistently below theoretical
  • Staff who volunteer to handle CS returns and destruction alone