Diversion Risk Assessment by Unit
Every clinical unit has a different drug profile, workflow, and vulnerability. Tailored monitoring strategies by care area.
Drug diversion risk is not evenly distributed across a clinical facility. The type of controlled substance most likely to be diverted, the methods used, and the monitoring gaps that enable it vary significantly by care area — and an effective diversion prevention program recognizes that distinction. A surveillance strategy built for a medical-surgical floor will not catch the patterns most common in an operating room or an intensive care unit.
This risk assessment organizes clinical settings by their inherent vulnerability profile, based on the types of controlled substances present, the workflows that create diversion opportunity, and the monitoring strategies that detect it earliest. Each unit is rated HIGH, ELEVATED, MODERATE, or SPECIALTY to help you prioritize where to invest review time, camera coverage, and reconciliation resources.
HIGH-risk units — including the emergency department, ICU, and pharmacy — handle large volumes of potent controlled substances with less consistent oversight and require frequent, proactive auditing: medication dispense cabinet override monitoring, waste witness rate analysis, and regular dispense-to-administration reconciliation. ELEVATED settings like the operating room carry substantial risk tied to anesthesia workflows and kit management. MODERATE-risk areas such as general medical-surgical floors still require structured monitoring, with particular attention to oral opioid accountability and fentanyl patch documentation.
Use this guide as a starting point, not a ceiling. Your facility's actual risk profile depends on patient census, staffing patterns, cabinet configuration, and any prior diversion history. Pair these unit profiles with data from your surveillance system — diversion patterns almost always appear in the data before they surface any other way. For a quantitative program evaluation, the program assessment checklist provides a weighted self-assessment of the elements a defensible program requires. If you're evaluating drug diversion monitoring software to cover these units, our buyer's guide walks through the categories of tooling and how to sequence adoption by risk tier.
Emergency Department
Highest Risk Drugs
- Fentanyl (IV push)
- Versed / Midazolam
- Ketamine
- Hydromorphone (Dilaudid)
- Morphine
- Propofol (procedural)
Common Diversion Methods
- Waste falsification — charting partial dose, keeping the rest
- Over-riding for "pain emergency" without order
- Diverting from multidose vials (ketamine, versed)
- Narcotic waste from trauma activations (unwitnessed)
Monitoring Strategy
- Override rate by practitioner — ED overrides are common but outliers matter
- Multidose vial yield — count doses per vial vs. expected
- Night shift waste patterns — less oversight after 2300
- Waste witness rate — % of waste events with valid witness
Red Flags
- Same nurse always managing the highest-acuity patients
- Frequent trauma assignments and consistently high waste
- Patients reporting pain despite charted fentanyl administration
- Nurse who stays late to "finish charting" alone
Intensive Care Unit
Highest Risk Drugs
- Propofol (large volume infusion)
- Fentanyl (drip and IV push)
- Versed / Midazolam
- Dexmedetomidine (Precedex)
- Hydromorphone PCA
- Ketamine (continuous infusion)
Common Diversion Methods
- Syringe swap — replacing full syringes with saline
- Diverting from multidose vials (propofol, insulin, heparin)
- PCA tampering — accessing reservoir or Y-site
- Over-reporting waste on drip changes
Monitoring Strategy
- Dispense vs. pump-log reconciliation for drips
- Propofol vial usage per patient — count vials opened vs. documented
- PCA waste volume vs. expected residual
- Infusion pump log audits — look for programming changes, restarts, pauses
Red Flags
- High waste rates on propofol and fentanyl drips
- Frequent PCA cassette changes with high residual
- Syringe swaps that coincide with colleague breaks
- Sedated patients who appear more alert than expected
Operating Room / PACU
Highest Risk Drugs
- Propofol (induction/maintenance)
- Fentanyl / Sufentanil
- Midazolam
- Succinylcholine / Rocuronium
- Ketamine
- Hydromorphone (PACU)
Common Diversion Methods
- Unwitnessed waste between cases
- Anesthesia cart tampering during off-hours
- Propofol vial diversion — drawing from multiple vials without documentation
- Pharmacy kit checkout / return discrepancies
- Fish eye / wide-angle cameras needed to cover moving anesthesia carts
Monitoring Strategy
- Anesthesia provider waste rate — per-case and per-drug
- Kit checkout → return reconciliation
- Case-level CS usage vs. expected based on procedure type
- After-hours OR access logs
- Camera footage — fish eye lens with privacy masking of surgical field
Red Flags
- Provider with consistently higher waste than peers for same procedure
- Missing or incomplete kit returns
- Anesthesia cart left unlocked or unattended
- Provider who frequently does add-on/emergency cases alone
Med-Surg / Telemetry
Highest Risk Drugs
- Oral opioids (oxycodone, morphine)
- Fentanyl patches
- PCA hydromorphone
- Hydromorphone IV push
- Diphenhydramine IV (non-controlled but diverted)
Common Diversion Methods
- Pocketing oral opioids — charting administered that were thrown away
- Fentanyl patch theft — charting placement but keeping the patch
- PCA tampering
- Waste falsification on IV push narcotics
Monitoring Strategy
- Oral opioid dispense vs. administration matching
- Fentanyl patch removal documentation audit
- PCA pump log vs. MAR reconciliation
- Waste documentation completeness by nurse
Red Flags
- Patients reporting pain despite opioid charting
- Fentanyl patch found loose in linen/bedding
- Same nurse has multiple patients with "uncontrolled pain"
- Frequent PRN opioid administration without pain score change
Oncology
Highest Risk Drugs
- Hydromorphone (IV and oral)
- Morphine (IV and oral)
- Fentanyl (IV and patches)
- Oxycodone (oral)
- Hospital-only oral opioids (infusion center formulas)
- Non-CS: diphenhydramine, ondansetron
Common Diversion Methods
- Patient-administered pump tampering (ambulatory infusion pumps)
- Oral opioid pocketing — large volumes dispensed to unit
- Returned medication theft — patient discharged, meds not returned
- Waste from patient-specific batches
Monitoring Strategy
- Patient pump return reconciliation — volume dispensed vs. returned vs. documented
- Unit-dose CS return tracking
- Oral opioid dispense-to-admin matching by shift
- Infusion center CS inventory — perpetual vs. physical
Red Flags
- High oral opioid returns — large numbers of "patient refused" doses
- Patient pump returns with less volume than expected
- Frequent breakthrough pain requiring IV push in infusion center
Pharmacy
Highest Risk Drugs
- Every controlled substance in the facility
- Bulk narcotic solutions
- Concentrated opioids for compounding
- Returned medications awaiting destruction
Common Diversion Methods
- ADC restocking diversion — pocketing during cart fill
- Inventory adjustment falsification
- Bulk compounding discrepancies
- Return processing diversion — pocketing returned CS, documenting destruction
- Unsupervised destruction — signing off waste that didn't occur
Monitoring Strategy
- ADC restocking variance — expected vs. actual for each technician
- Bulk compounding yield — units produced vs. raw drug used
- Inventory adjustment report — every CS adjustment with justification
- Return destruction log — witness verification for every destruction
- Camera coverage of compounding and restocking areas
Red Flags
- Same technician always restocking high-value CS cabinets
- Frequent "counting error" inventory adjustments
- Bulk compounding yields consistently below theoretical
- Staff who volunteer to handle CS returns and destruction alone
Frequently Asked Questions
Last reviewed: September 2026 · Content is educational, not legal advice.