Health system pharmacy leaders face the dual challenge of navigating a rapidly evolving drug supply chain while maintaining day-to-day compliance with controlled substance regulations across hospitals and clinics. Whether managing a single-site operation or directing a large academic health center, pharmacy teams consistently encounter issues related to medication procurement and internal oversight—processes that are critical to patient and community safety.
To address these challenges effectively, health systems must cultivate a culture rooted in awareness, transparency, and safety in medication use and drug diversion prevention. Although pharmacy typically plays a central role in diversion prevention, successful programs require collaboration across departments—including nursing, compliance, risk management, security, and executive leadership.
Navigating Regulatory Pressures
Over the past 5 years, an increase in Drug Enforcement Administration (DEA) inspections and enforcement actions has prompted health systems to develop more innovative approaches to diversion monitoring.1 At the same time, these organizations must respond to increasingly complex diversion tactics. According to the State of Drug Diversion 2025 Report, 25% of respondents identified compliance with federal and state regulatory requirements as a top priority for their executive boards regarding diversion prevention.2
Health systems are expected to implement robust policies and procedures that prepare them for unannounced DEA visits or follow-up from reported incidents.3 These inspections may involve evaluating physical spaces and equipment, such as automated dispensing cabinets, auditing controlled substance inventories, and reviewing required documentation for accuracy. Noncompliance can result in severe financial penalties, legal consequences, and disruptions to patient care.4 To protect staff and patients, diversion surveillance must be supported by a multidisciplinary team, strong leadership commitment, advanced technology, and regular assessments of regulatory readiness.
The American Society of Health-System Pharmacists emphasizes pharmacy’s leading role in medication management and controlled substance diversion oversight.5 Many organizations follow these guidelines, with the State of Drug Diversion 2025 Report confirming that pharmacy is recognized as a key stakeholder in most programs.2
Still, achieving broad multidisciplinary participation remains a challenge. For example, only one-third of respondents reported including anesthesiology—despite its high-risk nature—and just one-fifth involved human resources. Incorporating diverse professional perspectives enhances risk assessment and pattern detection while encouraging a culture of shared responsibility and vigilance.
The Case for a Multidisciplinary Approach
Each hospital system has distinct workflows to consider when forming a drug diversion committee. As regulations evolve, continuous evaluation of preparedness is essential. A multidisciplinary approach promotes shared accountability, timely communication, and proactive prevention. Assembling a core team that understands the unique operations of each department can improve the program’s efficiency.
Effective surveillance requires input from clinicians familiar with the nuances of different care settings. For instance, perioperative and procedural areas often have workflows distinct from general medical units. Involving perioperative specialists can be crucial in shaping appropriate policies and tailoring software solutions to meet specific needs.
Emergency departments bring their own challenges. The use of emergency kits and the need to act quickly—often with incomplete patient data—requires careful oversight. Paramedics and allied health professionals frequently assist with medication administration in these settings, demanding additional scrutiny. A nursing leader who understands these dynamics can improve protocols and support diversion-resistant workflows.
Pharmacy purchasing and distribution also vary depending on patient demographics and care delivery models. Ordering and receipt processes may be known only to a select few, making the insight of a pharmacy manager or operations director invaluable.
Centralized diversion detection programs have proven effective when they involve a range of professionals across the organization. For example, HCA Midwest in Kansas City, Missouri, highlights the value of pharmacy-nursing collaboration in preventing incidents before they occur.⁶
An ideal diversion committee should include representatives from pharmacy, nursing, compliance, informatics, security, and a physician champion. Where resources allow, consider expanding to include risk management, law enforcement, human resources, infection prevention, employee health, and diversion analysts.
To support program success, consider these practical steps:
- Clearly define departmental roles and responsibilities.
- Designate a chair or coleads to ensure accountability.
- Hold monthly meetings to review incidents, share insights, and refine strategies.
- Leverage technology to identify potential risks and prompt further review.
- Incorporate automation and artificial intelligence (AI) tools to enhance monitoring.
- Apply the 80/20 rule: Balance human oversight with technological efficiencies.
Leadership Support
Securing executive-level support is essential to building and maintaining a robust diversion program. Leadership’s understanding of the risks and benefits of effective surveillance can have lasting impacts on staff well-being, patient safety, and community trust. A gap analysis is a helpful tool to assess current capabilities and highlight areas for improvement.
Key questions to ask leadership include the following:
- Do we have the staffing needed to cover all high-risk areas?
- Can existing staff be trained, or are additional hires necessary?
- Are outdated or limited data systems hindering effective reporting?
- Would AI-driven software enhance monitoring in high-risk units?
- Are surveillance systems in place, such as cameras, to support detection?
Once these questions are addressed, program leads should develop a business case to advocate for staffing and resource expansion. Emphasize that technology is most impactful when used in conjunction with well-trained professionals and clearly defined policies.
Building a Culture of Safety
Fostering a culture of safety is vital to protecting patients, staff, and the broader community. Everyone should be committed to ongoing education about drug diversion—including risks, recognition, reporting processes, and response protocols.
Consider the following when evaluating your organization’s safety culture:
- Do staff know how to report concerns confidentially and without fear of retribution?
- Are surveillance tools, policies, and training materials current?
- Do existing protocols promote collaboration and accountability?
- Are support systems in place for staff dealing with substance use disorders?
Encouraging nonpunitive reporting creates a safer environment and strengthens team trust. Ongoing training, especially for new staff, helps reinforce standards. Sharing anonymized case studies internally can demonstrate the benefits of early detection and continuous improvement. Diversion surveillance must be a shared responsibility supported by executive leaders and a committed multidisciplinary team.
Conclusion
About the Author
Stacey McCoy, PharmD, MS, BCPS, has over 20 years’ experience as a clinical pharmacist and is pharmacy clinical program manager for the clinical surveillance and compliance business at Wolters Kluwer. McCoy’s most recent clinical practice included more than 12 years’ experience as an adult emergency medicine specialist. McCoy’s areas of expertise include critical care, acute care cardiology, neurology, neurocritical care, and medication safety.
McCoy received her doctor of pharmacy degree from Mercer University and her bachelor’s and master’s in chemistry from Clark Atlanta University in Georgia. McCoy also completed her PGY-1 pharmacy practice residency at St Joseph’s/Candler in Georgia. McCoy has earned her certification in pharmacogenomics from Mayo Clinic and is an active member of the American Society of Health-System Pharmacists.
Controlled substance monitoring and regulatory compliance continue to evolve, demanding flexible and responsive strategies. Best practices highlight the importance of assembling a diverse team to evaluate current systems and standardize processes for safe medication management.
Although pharmacy leaders are key drivers, diversion prevention is a collective responsibility. Achieving meaningful impact requires investment and engagement across the health system. Regular dialogue with leadership, supported by performance data, helps sustain long-term program success. By promoting a culture of safety, leveraging technology, and encouraging cross-department collaboration, health systems can proactively address drug diversion and create a safer, more resilient care environment for all.
REFERENCES
Nurse pleads guilty to illegally obtaining fentanyl from hospital. News release. DEA. December 16, 2024. Accessed May 9, 2025. https://www.dea.gov/press-releases/2024/12/16/nurse-pleads-guilty-illegally-obtaining-fentanyl-hospital
The State of Drug Diversion Report. Wolters Kluwer. May 16, 2025. Accessed May 9, 2025. https://www.wolterskluwer.com/en/expert-insights/the-state-of-drug-diversion-report
Hospital in Washington agrees to pay $15,000 penalty and implement corrective actions to address theft of controlled substances. News release. DEA. November 18, 2024. Accessed May 9, 2025. https://www.dea.gov/press-releases/2024/11/18/hospital-washington-agrees-pay-15000-penalty-and-implement-corrective
Boston physician resolves allegations of improper prescribing practices involving controlled substances. News release. DEA. September 11, 2024. Accessed May 9, 2025. https://www.dea.gov/press-releases/2024/09/11/boston-physician-resolves-allegations-improper-prescribing-practices
Clark J, Fera T, Fortier C, et al. ASHP guidelines on preventing diversion of controlled substances. Am J Health Syst Pharm. 2022;79(24):2279-2306. doi:10.1093/ajhp/zxac246
Nyhus J. Drug diversion in healthcare: prevention and detection for nurses. American Nurse Journal. 2021;15(5):26-30. Accessed May 9, 2025. https://www.ismp.org/sites/default/files/attachments/2021-05/an5-Drug%20Diversion-406a%20%282%29.pdf
