CASE STUDY
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didn’t know it was happening. And they didn’t know what to look for or how to address it if they
suspected a case.
Diversion wasn’t top of mind at the hospital. It was my job to raise awareness that it is still an
issue. We put diversion detection at the forefront of our staff education program.
Q. How did Wake Forest Baptist Health deal with diversion?
While I was the diversion analyst, the chief nursing, pharmacy, and legal officers led an executive
oversight committee on diversion. They also bring in communications and compliance to
advise on policies and situations. This committee established the Drug Diversion Prevention
and Response Team, which regularly informs committee members about the state of diversion,
current issues, and possible diversions.
The team continually mitigates diversion risk by analyzing clinical practice workflows because
someone who will divert will find weaknesses, permitting the possibility of diverting throughout
the system.
Q. What solutions are Wake Forest Baptist Health applying? Are they successful?
As an analyst, technology that allowed me to pull documents into one system and validate the
data make my job easier and more successful.
Q. What resources are needed to monitor diversion of controlled substances?
Resource need depends on the area in the hospital. Monitoring med surge is different than reviewing
controlled substances in general nursing. If you must put a case together, you have to have tools
and resources that substantiate the case because we don’t want to accuse people falsely.
Q. With the abundance of data analytics available today, how do you use the data to make an
informed decision?
Data allows us to identify trends and pinpoint issues quickly. Analytics is a needed piece of the
puzzle when putting a case together. It’s a big benefit to having analytics.
Q. What is the essential data point to detect diversion?
One of the easiest and earliest is to focus on where the highest level of dispensing is occurring.
A good start is examining the top five or ten users dispensing narcotics and why they are
dispensing. Is it because they work in oncology or the ICU where high usage occurs? It’s about
trust and verification.
Q. Based on your expertise, what is your guidance on a monitoring system for drug diversion?
This work is not trying to “catch” someone but rather mitigate a problem that could potentially
harm the patient. People don’t want to discuss diversion, but you must discuss it.
Final Thoughts From Patricia
Getting executive buy-in from the start was critical for the diversion prevention team. Leadership
put an organized structure around addressing diversion, making it an organizational priority.
This work is not
trying to 'catch'
someone but rather
mitigate a problem
that could potentially
harm the patient.
People don’t want to
discuss diversion, but
you must discuss it.”
Patricia Penland, RN
Retired Drug Diversion
Surveillance Analyst
~ Wake Forest Baptist Health,
Winston-Salem, NC