Insights from a National Survey on Controlled Substance Diversion Practices in U.S. Hospital Pharmacies: Opportunities for Enhanced Surveillance and Compliance

Abstract

This study explored controlled substance (CS) diversion surveillance practices within hospital pharmacies across the United States. A survey with questions based on published CS diversion risk points was conducted in May 2024. A total of 66 participants from 31 states responded, with 54.5% from single facilities and the remaining from health systems. Most respondents were pharmacy directors, managers, or those in dedicated drug diversion roles. Over 70% have dedicated surveillance teams and use drug diversion software. Results highlight variation in practices, with larger institutions generally showing better compliance. Compliance in procurement and receiving was high for access measures; however, auditing of processes was lower. The lowest procurement compliance was in monitoring periodic automatic replacement (PAR) levels and validating orders with wholesalers. Storage practices showed high compliance in deploying cameras, but low compliance in monitoring them. Dispensing practices had high compliance for restricting CS in automated dispensing cabinets, but low incidence of witness verification during stocking. Waste and disposal practices were well-followed, but training on detecting potential signs of medication tampering was less common. The survey highlights that while strategies to prevent CS diversion exist, their implementation varies. Enhancing monitoring, auditing, and training is essential to strengthen diversion prevention efforts in hospital pharmacies.

Keywords: controlled substances; diversion; healthcare safety; hospital pharmacy; patient safety.

Figure 1

Procurement and Receiving Survey Responses.

Figure 2

“How often do you audit invoices against the receiving purchase order for CS?”.

Figure 3

“How often do you audit invoices against the controlled substance vault records?”.

Figure 4

“Per your organization policy and procedure, how soon after receiving controlled substances inventory in the pharmacy should it be entered into the vault?”.

Figure 5

“Approximately what percent of the time is your staff able to meet the policy and procedure for time from controlled substances inventory receipt to entering into the vault?”.

Figure 6

Storage, Packaging and Compounding Survey Responses.

Figure 7

“How often are key and access codes audited and updated?”.

Figure 8

(a) “Does your facility rotate roles associated with inventory management?”. (b) “If Yes to [previous question], Which roles are regularly rotated? (select all that apply)”.

Figure 9

“How often is an audit performed on the controlled substances vault at your facility?”.

Figure 10

“Does your organization have a process for storing and auditing controlled substance multi-dose vials and bulk bottles when they are not in use?”.

Figure 11

“Per your organization policy or procedure, how soon are repackaged and/or bulk bottles returned to the vault (e.g., time waiting for verification before return to vault)?”.

Figure 12

“Does your organization have a policy about how to address over/underfill in vials and bottles of controlled substances?”.

Figure 13

“For which of the following classes does your facility use blind counts in vaults for controlled substance medications? (select all that apply)”.

Figure 14

“For which of the following classes does your facility use blind counts in automated dispensing cabinets (ADCs) for controlled substance medications? (select all that apply)”.

Figure 15

Dispensing Survey Questions.

Figure 16

“How soon does your organization require investigation of occurrences of controlled substance inventory count adjustments and discrepancies made by pharmacy personnel? (Either in ADCs or Vault)”.

Figure 17

Waste, Return and Disposal Survey Responses.

Figure 18

“Does your organization use assay technology to audit wasted drugs?”.

Figure 19

“How often is your reverse distributor bin emptied?”.

Figure 20

“How often is the inventory in the controlled substance reverse distributor bin audited (e.g., prior to being sent to reverse distributor)?”.