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
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
- 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.
- Immediate testing for BBP of the health care personnel suspected/confirmed
of injectable medication diversion;
- Notification of patients at risk for BBP transmission
due to injectable medication diversion and recommendations for follow-up of BBP
- 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.
- 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.
- 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.
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.
online: June 01, 2014.
- Centers for Disease Control and Prevention Drug Diversion Website
- Minnesota Controlled Substance Diversion Prevention Coalition Final Report, March 2012.