CDC Report Says Patients Harmed by Drug Diversion

When prescription medicines are stolen or used illegally, it is called drug diversion. One aspect of drug diversion that is not well recognized involves healthcare providers who steal controlled substances for their personal use. A report authored by experts from the Centers for Disease Control and Prevention (CDC) -- published today in Mayo Clinic Proceedings -- outlines outbreaks of infections that have occurred as a result of healthcare providers stealing or tampering with their patients' medications. These outbreaks revealed gaps in prevention, detection, and response to drug diversion.

"Patient harm stemming from diverting injectable drugs can include patients not obtaining adequate pain management, exposure to substandard care from an impaired provider, and exposure to life-threatening infections," according to study co-authors Melissa K. Schaefer, MD, and Joseph F. Perz, DrPH, of the Division of Healthcare Quality Promotion of the National Center for Emerging and Zoonotic Infectious Diseases at the CDC.

Over the past 10 years, outbreak investigations related to healthcare provider drug diversion have documented more than 100 infections and nearly 30,000 patients potentially exposed to bloodborne or bacterial pathogens. The frequency with which these events have been detected appears to be increasing.

The review identified six outbreaks within hospital settings located in eight states over a 10-year period beginning in 2004. Implicated health care professionals included three technicians and three nurses. In four of these outbreaks the implicated healthcare professional was infected with hepatitis C virus and served as the source of disease transmission to patients. Two other outbreaks resulted from improper drug handling by drug-diverting healthcare professionals infecting patients with bloodstream bacterial infections.

"The outbreaks we have identified illustrate some of the devastating and wide-reaching impacts of drug diversion in U.S. healthcare settings," note Schaefer and Perz. "Healthcare facilities should ensure that patients safely receive medications as prescribed. This effort includes having systems in place to prevent drug diversion as well as developing protocols for early detection and appropriate response if, despite safeguards, diversion does occur."

To prevent diversion, healthcare facilities should enforce strong narcotics security measures and maintain active monitoring systems. Appropriate response when diversion is suspected or identified includes prompt reporting to enforcement agencies and assessment of harm to patients, including assessment of possible infection risks.

"This report serves notice that all healthcare facilities that house controlled substances or other drugs of abuse must have effective systems in place that deter drug diversion," comment Keith H. Berge, MD, and William L. Lanier, MD, of the Department of Anesthesiology, Mayo Clinic, Rochester, Minn., in an accompanying editorial. "Further, those facilities must be able to quickly and effectively investigate when a drug diversion is suspected in an effort to limit the number of patients potentially exposed to harm. The increasing incidence of drug diversion makes it mandatory that drug control be improved."

On CDC’s Safe Healthcare Blog, Kimberly New, JD BSN RN, president of the Tennessee Chapter of the National Association of Drug Diversion Investigators, breaks down the issue of drug diversion and details the consequences of healthcare providers stealing controlled substances meant for their patients. Join the conversation at: http://blogs.cdc.gov/safehealthcare

Source: CDC