A conceptual framework for identifying and managing system vulnerabilities for diversion of controlled substances in healthcare

Purpose

Diversion or theft of controlled substances is a recognized problem affecting healthcare systems globally. The purpose of this study was to develop a framework for identifying and characterizing system factors leading to vulnerabilities for diversion within hospitals.

Methods

We applied a qualitative framework method, which involved 1) compiling a list of critical diversion vulnerabilities through observations and proactive risk analyses in the inpatient pharmacy, emergency department and intensive care unit of two Canadian hospitals; 2) coding the vulnerabilities into deductively and inductively derived themes and subthemes; and 3) building a conceptual framework.

Results

Our framework for diversion demonstrates how mitigating downstream diversion outcomes (e.g., harms to patients, healthcare workers, and institutions) requires the redesign of upstream system factors associated with pilfering and forgery processes. We identified 20 subthemes associated with the following five overarching themes of system factors contributing to diversion risk: task (e.g., variation in how work was done or lack of verification), person (e.g., use of insider knowledge or collaboration among staff), tools/technologies (e.g., limitations of electronic systems to identify discrepancies), organization (e.g., cultural/behavioural norms or hospital policies for controlled substance management), and internal environment (e.g., layout of the space).

Conclusion

The Diversion Framework is a conceptual model developed for use by practitioners, researchers, and policy makers to identify system factors and analyze medication-use processes that may be vulnerable to diversion. This in turn can inform safeguards to prevent harm to patients, healthcare workers and the institution.