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Monitoring drug diversion: Top 5 recommended reports and what to look for
Insider survey results
25% of hospitals reading Insider responded to our survey on diversion prevention View the results
The Insider is covering diversion prevention with a 3 part series of articles on this critical topic. The first article underscored the seriousness and prevalence of drug diversion and outlined recommended hospital polices and supporting products that can be put in place to help prevent drug diversion. This second article will build upon the theme by focusing on recommended Cardinal Health tools and reports to monitor for potential drug diversion activity. While prevention is the ultimate goal, monitoring is the key to communicating your diligence about diversion and ensuring you have the data to support action if necessary.

Common report name Technical name of report
(as you would find it in the system)		 Product used to run report
Proactive Diversion report Proactive Diversion Search Pyxis® CIISafe™ system
Controlled Substance Analysis Pyxis® Consultant data mart software version 1.75
Pyxis® CIISafe™ Compare report Pyxis vs. CIISafe Compare Pyxis® CIISafe™ system
Controlled Substance Profile Override report Profile Override report Pyxis® MedStation™ console
CS Overrides by User:  Custom query Pyxis® Reporter software
Override Analysis Pyxis® Consultant data mart software version 1.75
Discrepancy report by prior user and discovering user CS-Discrepancy by User Pyxis® Reporter software
Discrepancy query Pyxis® Consultant data mart software version 1.75
User Modification report User Modification report Pyxis® MedStation™ console

To view more reports and tools for diversion prevention see our best practice document [pdf file – 89 Kb].

Report analysis
In the 2005 American Society of Health System Pharmacists’ survey of dispensing practices, Pedersen et al reported that 71.8% of all hospitals use Automated Dispensing Cabinets (ADCs) in their drug distribution systems. This figure rose to 92.5% for hospitals with more than 399 staffed beds. … A controlled substance vault, if of the same vendor type as the institution’s ADCs, can easily interface with an ADC and allow reconciliation of transactions to or from the vault.

Siegel, J; O’Neal, B. Diversion in the Pharmacy1
A proactive drug diversion search is generated monthly to determine which automated dispensing users are withdrawing controlled substances more frequently than their peers.

Siegel, J; O’Neal, B. Diversion in the Pharmacy1

The controlled substance manager runs a series of reports on a monthly basis starting with the proactive diversion report.

Siegel, J; O’Neal, B. The Investigative Process2
It is important that the appropriate peer group is selected. If you were to compare controlled substance removals on an orthopedic unit with an internal medicine unit, the usage reports themselves would have wide fluctuations.

Siegel, J; O’Neal, B. Code N: Multidisciplinary Approach to Proactive Drug Diversion Prevention3

Proactive Diversion report
Product: Pyxis® CIISafe™ system (Proactive Diversion Search), Pyxis® Consultant data mart software (Diversion Analysis)

Reviewer: Pharmacy Managers and Nurse Managers

Frequency: Run monthly by nursing units with similar patient types. In large facilities, you may want to run 1-2 units each day, but be sure that each unit is run monthly.

Purpose: This report will identify individuals that have removed significantly more controlled substances than their peers.

How to generate report:

Proactive Diversion Search report on the Pyxis® CIISafe™ system
  1. Select Reports from the menu
  2. Select Quality Assurance Reports
  3. Select Proactive Diversion Search
  4. The report date range will default to the last 30 days, enter the date range you want
  5. Select the unit or similar units you want to review
  6. Select All Meds
  7. Select 2+ standard deviations
  8. Check Show detail
  9. Run the report. It may take several minutes to run

Diversion Analysis report on the Pyxis® Consultant data mart software version 1.75
  1. Select the Controlled Substance Analysis Query from the Query menu
  2. Click on the “Click here to process button”
  3. Select facility, if prompted
  4. Select desired nursing units, if prompted
  5. Select medication class, if prompted
  6. When data is returned, select Summary By Station Report on All Users


What to look for? Once the report is generated, look for anyone that is 2 or more standard deviations above the mean. An individual that is 2 standard deviations above the mean removed more doses of controlled substances per day worked than 95% of the staff on that unit. Someone that is 3 standard deviations above the mean removed more doses of controlled substances per day than 99% of the staff on the unit.
NOTE: Results may differ on the diversion reports based on the methods used for statistical analysis.

What if I find something? Next steps: All individuals exceeding 2 standard deviations should be investigated. There may be a legitimate reason why a staff member is on the Proactive Diversion report, such as:
  • Clinician had longer than standard shifts
  • Clinician had a "finger stutter" error – hit 11 instead of 1
  • Clinician had a patient requiring large amounts of pain medication for several days
  • Individual removed a medication that is in the formulary in mls (quantity is 30 rather than 1)

However, the individual could be diverting if they are on this report. To get more details on this individual, run the Pyxis® MedStation™ system report from the Pyxis® CIISafe™ system for the user in question. Review for removal quantities > 2, drug of choice and consistent PRN removals for the shortest dosing interval ordered. The All Stations Event Report from the Pyxis® MedStation™ console (limited to a particular patient) can also be used to determine if the patients identified as receiving pain medication at frequent intervals required the same amount of pain medication on other shifts.

The next Insider article in our series on drug diversion will outline appropriate next steps once you have gathered your documentation.

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Review all transactions involving movement of controlled substances out of the pharmacy (e.g., from the pharmacy to an ADC or satellite pharmacy) to ensure that diversion did not take place between the pharmacy and the end destination.

Siegel, J; O’Neal, B. , Diversion in the Pharmacy1

By performing and monitoring regularly scheduled audits, trend analyses, and database assessments, drug diversion activities can be identified early.

Fleming, K; Boyle, D; Lent, W.J.; Carpenter, J; Linck, C. A Novel Approach to Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy Compliance Officer4

Pyxis® CIISafe™ Compare report
Product: Pyxis® CIISafe™ system

Reviewer: Technicians and Pharmacy Managers

Frequency: Run by shift or at least daily after all controlled substances are refilled and delivered.

Purpose: This report matches items sent from the Pyxis® CIISafe™ system with items received in the Pyxis® MedStation™ unit.

How to generate report:

Pyxis® vs. CIISafe™ Compare report on Pyxis® CIISafe™ system
  1. Select Reports from the menu
  2. Select Quality Assurance Reports
  3. Select Pyxis vs. CIISafe Compare Report
  4. Enter the date and time range
  5. Select the nursing units
  6. Run the report


What to look for? The Pyxis® vs CIISafe™ Compare report is an exception report. Look for controlled substances that have a send transaction without a receive transaction. This indicates that a controlled substance was issued to a Pyxis® MedStation™ unit from Pyxis® CIISafe™ system, but it was not refilled into the Pyxis® MedStation™ unit. Also check that the controlled substances that are unloaded, removed from the return bin or expired from the Pyxis® MedStation™ unit are returned to the Pyxis® CIISafe™ system.

What if I find something? Next steps: A send transaction without a receive transaction can be due to a refill error, a delay in delivery or diversion. The controlled substance may have been refilled to the wrong pocket or the wrong Pyxis® MedStation™ unit. Look at the report for receive transactions without a send transaction for other Pyxis® MedStation™ units and for different strengths of the controlled substance. Investigate to make sure the delivery did not occur after the report was printed. If the person delivering the controlled substance was different from the individual removing the medication from Pyxis® CIISafe™ system, be sure to interview both.

The next Insider article in our series on drug diversion will outline appropriate next steps once you have gathered your documentation.

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Controlled Substance Profile Override report
Product: Pyxis® MedStation™ console, Pyxis® Reporter software, Pyxis® Consultant data mart software

Reviewer: Pharmacist or Pharmacy Manager

Frequency: Weekly

Purpose: Review for an unusually high amount of controlled substance removal on override.

How to generate report:

Profile Override report from the Pyxis® MedStation™ console
  1. Select Reports from the menu
  2. Select Activity Reports
  3. Select Profile Override Report
  4. Select Sort by User
  5. Enter the date range
  6. Use the select button beside Med Class to limit the report to scheduled medications
  7. Run the report

CS Overrides by User Query in the Pyxis® Reporter software
  1. Select the month from the menu
  2. Select the Query tab
  3. Select All Station Events from the query menu
  4. Limit the Transactions to WITHDRAWN
  5. Limit stations to profile units
  6. Drag down the order number and limit order number to Override
  7. Drag down med class and limit med class to ‘2’ OR ‘3’ OR ‘4’ OR ‘5’
  8. Sort by user
  9. Run the report

Override Analysis Query in Pyxis® Consultant data mart software version 1.75
  1. Select the Override Analysis Query from the query menu
  2. Select Click Here to Process
  3. Select Facility if prompted
  4. Select MedStations if prompted
  5. Select Medication Class if prompted
  6. When data returns, select Results
  7. If you were not prompted to limit medication class previously, limit medication class to desired controlled substance classes
  8. Select the Override with No Orders report


What to look for? Once the report is generated, look for users that have more overrides for controlled substances than their peers.

For the individuals who have a high standard deviation, a second report is generated from the Pyxis server. It contains each transaction of a controlled substance that has been initiated by this specific nurse during the same time frame. Any removal, return, waste, inventory, or cancelled transaction is included in this transaction record.

Siegel, J; O’Neal, B. The Investigative Process2

What if I find something? Next steps: Check in the pharmacy information system or the patient chart to see if there is an order for each override. An occasional override without an order may be due to a failure to transcribe a verbal order. This is a compliance and education issue, not a diversion issue. If a user has multiple overrides without orders, further investigation for diversion is warranted. Review the patient medication administration record to determine if the override was charted as given. Patient interviews may be necessary to determine if the medication was actually administered. The nurse manager should assist with this step. Additionally, run an All Station Events report sorted by patient, limited to the user and limited to controlled substances. Review for dosing intervals shorter than the ordered frequency and doses consistently removed for the shortest dosing interval ordered. Run the All Station Events report again, this time limited to the patients identified as receiving pain medication at frequent intervals to see if the patients required the same amount of pain medication on other shifts.

The next Insider article in our series on drug diversion will outline appropriate next steps once you have gathered your documentation.

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Discrepancy report by prior user and discovering user
Product: Pyxis® Reporter software, Pyxis® Consultant data mart software

Reviewer: Pharmacy Manager

Frequency: Daily to weekly

Purpose: Run this report to determine which individuals are creating discrepancies and to determine if the same individual is “always” discovering discrepancies. This report is also useful for reviewing the resolution reasons to see if they are appropriate.

How to generate report:

CS-Discrepancy by User report from the Pyxis® Reporter software
  1. Select the month from the menu
  2. Select the Monthly Reports tab
  3. Select the nursing stations
  4. Enter the date range
  5. Select Continue to run the report
  6. “P user” is the prior user; “D user” is the discovering user

Discrepancy Query in Pyxis® Consultant data mart software version 1.75
  1. Select the Override Analysis Query from the query menu
  2. Select Click Here to Process
  3. Select facility if prompted
  4. Select MedStations if prompted
  5. Select Medication Class if prompted
  6. If not prompted to select class previously, limit to desired medication class


What to look for? Look for individuals that appear on the report several times as the prior user or as the discovering user. Review discrepancy reasons to see if they make sense.

What if I find something? Next steps: This report is not an appropriate tool for areas that only have a few nurses. If a nurse appears on the report several times as the prior user, you will need to investigate to determine if it is an education issue or a diversion issue. Individuals appearing several times as the discovering user should be investigated as well. The discovering user could actually be using this method to divert, since most individuals will assume the prior user is the diverter. Use the Pyxis® MedStation™ system report from Pyxis® CIISafe™ system and the All Station Events report (limited to user and controlled substances) from the Pyxis® MedStation™ console to look for suspicious practices such as removals greater than two, frequent overrides and doses consistently removed at the shortest dosing interval.

The next Insider article in our series on drug diversion will outline appropriate next steps once you have gathered your documentation.

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User Modification Report
Product: Pyxis® MedStation™ console

Reviewer: Pharmacy Managers and Nurse Managers

Frequency: Weekly

Purpose: Review to make certain users added or modified at the Pyxis® MedStation™ console are legitimate. Also to make sure temporary users added are legitimate.

How to generate report:
User Modification Report from the Pyxis® MedStation™ console
  1. Select Reports from the menu
  2. Select System Activity Reports
  3. Select User Modification Report
  4. Enter desired date range
  5. Run report


What to look for? Once the report is generated, look to see who in the pharmacy is adding users. Is this individual authorized to add users? If your hospital allows the use of temporary users, look at who the temporary users are and who created them.

What if I find something? Next steps: Contact the Nurse Manager to determine if users added at the Pyxis® MedStation™ console and temporary users added at the Pyxis® MedStation™ unit are really employees and are assigned to that area. If a user is not legitimate, run an All Station Events report (limited to the user) to determine if there is any activity or if it was an entry mistake.

The next Insider article in our series on drug diversion will outline appropriate next steps once you have gathered your documentation.

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Insider survey results
25% of hospitals reading Insider responded to our survey on diversion prevention, and here’s what they said:

92% of hospitals* have a process for removing terminated users.
35% of hospitals review their diversion policies during orientation.
88% of hospitals resolve discrepancies on a daily basis.
71% of hospitals encourage wasting medication at the point of removal when dose removed exceeds the patient’s ordered dose.
76% of hospitals have two different individuals performing ordering and receiving of controlled substances.

*Number represents the percentage of hospitals that responded to the survey. For survey details contact us.
Related links References
  1. Siegel, J; O’Neal, B. Diversion in the Pharmacy. Hospital Pharmacy. 2007;42:145-148
  2. Siegel, J; O’Neal, B. The Investigative Process. Hospital Pharmacy. 2007;42:466-469
  3. Siegel, J; O’Neal, B. Code N: Multidisciplinary Approach to Proactive Drug Diversion Prevention. Hospital Pharmacy. 2007;42:244-248
  4. Fleming, K; Boyle, D; Lent, W.J.; Carpenter, J; Linck, C. A Novel Approach to Monitoring the Diversion of Controlled Substances: The Role of the Pharmacy C
  5. ompliance Officer. Hospital Pharmacy, 2007
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