Minnesota Hospital Association

Quality & Patient Safety

July 23, 2014

Minnesota Patient Safety Alert: Controlled substance diversion can lead to health care-associated infection

This safety alert is issued to encourage continued implementation of the recommendations to prevent and report drug diversion and also to highlight specific actions required to prevent and respond to the threat of health care–associated infections resulting from drug diversion by health care personnel. 


The Controlled Substance Diversion Coalition, convened in 2011-2012 by the Minnesota Department of Health and the Minnesota Hospital Association, was a broad-based stakeholder forum convened to identify and share strategies to increase awareness of and prevent controlled substance diversion within hospitals. The coalition’s final report in March of 2012 included data from the U.S. Drug Enforcement Administration (DEA). There were 250 reports to the DEA of theft or loss of controlled substances attributable to health care personnel diversion from pharmacies within hospitals, clinics, and outpatient surgery centers in Minnesota from 2005 to 2011. And, the number of reports increased from 16 in 2006 to 52 in 2010, an increase of 325 percent.  

New reports of theft or loss from 2011 – August 2013

Preliminary data of health care personnel diversion in pharmacies within hospitals, clinics, and outpatient surgery centers as reported to the DEA through August 2013 was shared with MDH. There were 65 reports in 2011 and 104 in 2012. The number of reports doubled from 2010 to 2012. For the first eight months of 2013 there were 69 reports which was on-pace to exceed 2012 numbers. Thirty-one percent of the medications diverted were intravenous or intramuscular medications. This percentage has remained relatively consistent over time.   

The coalition anticipated that the number of reports would increase in subsequent years as a result of the coalition’s efforts to raise awareness of the problem of diversion and to implement requirements and recommendations. 

Diversion of injectable medication represents a risk for transmission of blood borne pathogens (BBP) and for bacteremia. A recent review by the Centers for Disease Control and Prevention (CDC) identified six outbreaks of bacterial and hepatitis C virus (HCV) infections that resulted from drug diversion by health care personnel in U.S. health care settings in the past 10 years. 


  1. As diversion of an injectable medication can represent a BBP transmission risk similar to other types of healthcare BBP exposures, review and update BBP exposure protocols and controlled substance diversion prevention policies to address issues specific to injectable medication diversion. 
      1. Immediate testing for BBP of the health care personnel suspected/confirmed of injectable medication diversion;
      2. Notification of patients at risk for BBP transmission due to injectable medication diversion and recommendations for follow-up of BBP testing.
  2. Contact the of Minnesota Department of Health Infectious Disease Division for consultation regarding BBP risk assessment to patients at 651-201-5414 or toll-free at 877-676-5414.
  3. Conduct a gap analysis with the Minnesota Controlled Substance Diversion Prevention roadmap. Develop action plan including law enforcement notification based on roadmap and tool kit.
  4. Review and comply with reporting requirements, now including mandatory reporting to licensing boards. In addition to previous reporting requirements, a newly-adopted law requires health care entities to report to a licensed professional’s licensing board when the entity has knowledge of a drug diversion by the licensed professional at their facility.


  1. Melissa K. Schaefer, MD, Joseph F. Perz, DrPH, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, Outbreaks of Infections Associated With Drug Diversion by US Health Care Personnel. Published online: June 01, 2014. 
  2. Centers for Disease Control and Prevention Drug Diversion Website
  3. Minnesota Controlled Substance Diversion Prevention Coalition Final Report, March 2012.