Signs of Diversion
It is important to watch for signs of diversion in person and on paper, meaning, you need to watch staff’s behaviors and pay attention to documentation.
Behavioral Signs
When it comes to suspected staff diversion, employees may:
- Appear drowsy or agitated.
- Exhibit symptoms such as sweating, chills, and runny nose.
- Miss a lot of work, come in late or leave early and/or complain a lot about being sick.
- Have poor job performance and/or make more mistakes.
- Have diminished personal relationships.
- Take extended breaks.
- Become less alert and/or experience memory lapses.
Another sign involves residents who complain more about pain on certain shifts. Hearn noted, “If you have someone who can’t really communicate, they are at greater risk of having their drugs taken from them. Watching these individuals for signs of pain, particularly if they are on medications designed to ease their discomfort, can help identify diversion issues and make sure these patients don’t suffer.” A staff member always wants to cover residents who on particular medications may be a warning as well.
As for diversion involving residents, common behaviors include:
- Questionable stories about why they need pain meds or how they got an unusual injury. If a story doesn’t seem right, it is appropriate to conduct further assessments and/or seek input from another clinician. Particularly savvy individuals may wait until the end of the day or shift changes when they think they are more likely to get the medications they want.
- Lack of cooperation. For example, they may be resistant to non-opioid pain medications or nonpharmacologic interventions, instead insisting that only an opioid will help them.
- Unusual level of medication knowledge. It may be a red flag if someone seems to be extremely knowledgeable about specific medications. Conversely, they may pretend to know nothing about medications that they have a history of using.
Documentation Warnings
Paperwork can also reveal suspected diversion. Keep a close eye on documentation and processes, specifically:
- Monitor medication waste and watch for outliers. Hearn offered, “Does waste often or always involve a particular person or persons?” By watching for trends or changes (such as waste “buddies” on the shift covered by a particular nurse), you can identify possible diversion issues. At the very least, you may identify a need for additional staff training and/or support. Also watch for a missing or inaccurate documentation regarding waste, as well as someone asking colleagues to sign off on waste they didn’t witness firsthand.
- Make sure staff are doing counts/documentation regarding controlled substances at shift change.
- Watch for frequent requests for supplemental controlled substance orders or alteration of telephone or verbal medication orders.
- Make sure that drug destruction processes are being followed and documented accurately and promptly.
- Ensure that staff are thoroughly trained about diversion. Not only should they be educated on processes to identify signs of diversion and how to report suspicions or concerns; it is important to emphasize that preventing diversion is a priority for the organization and that policies, procedures, and protocols must be strictly followed.