Is Diversion Mitigation as Important as Falls Prevention?

Ask any hospital administrator whether falls prevention is a patient safety priority, and the answer is immediate and unqualified. Yes. Of course. We have a program. We have protocols. We have data. We have accountability. We train our staff, we measure our outcomes, and we report to leadership.

Now ask that same administrator whether drug diversion mitigation receives the same level of institutional attention.

The pause that follows is itself an answer.

I have been asking this question — sometimes directly, sometimes indirectly — for years. And what I have found is not that healthcare leaders are indifferent to diversion. Most are not. What I have found is that diversion mitigation occupies a different category in the institutional consciousness — one that is treated as a compliance function rather than a patient safety function, as a pharmacy problem rather than an organizational priority, as something that gets addressed when a concern surfaces rather than something that requires the same proactive, sustained, resourced attention that falls prevention receives.

That categorization is worth examining. Because when you look at what diversion actually costs patients — not the regulatory exposure, not the reputational risk, but the direct patient harm — the case for treating diversion mitigation as a first-tier patient safety priority becomes difficult to argue against.

If diversion mitigation is not yet a first-tier patient safety priority in your organization, the question worth asking is why — and what it would take to change that. Schedule a free 30-minute assessment with Rxpert Solutions. That conversation is exactly where we start.

What the comparison actually reveals

Falls prevention became the institutional priority it is today because the patient harm was visible, measurable, and impossible to ignore. A patient falls. There is an incident report. There is a root cause analysis. There is a corrective action. Leadership sees the data. The pattern is tracked over time. The program evolves in response to what the data shows.

That cycle of visibility, accountability, and improvement is what makes falls prevention effective as a patient safety program. And it is almost entirely absent from how most healthcare organizations approach diversion mitigation.

Diversion harm is less visible than falls harm — not because it is less real, but because it is harder to see. The patient who did not receive adequate pain relief because their medication was diverted rarely generates an incident report that is coded as a diversion consequence. The patient who received a diluted or contaminated substitute may experience an adverse event that is attributed to other causes. The connection between the diversion and the patient harm is often never made — not because it does not exist, but because the systems that would make it visible have not been built.

That invisibility is not an argument that diversion harm is rare. It is an argument that our systems for detecting and documenting it are inadequate.

Building the systems that make diversion harm visible — before it becomes undeniable — is precisely the work that Rxpert Solutions does with healthcare organizations. Book a complimentary 30-minute consultation to talk about what those systems look like in your facility.

The institutional infrastructure gap

Falls prevention works as a patient safety program because it has institutional infrastructure behind it. A designated champion. Defined protocols. Staff education that is ongoing and competency-based. Data reviewed at regular intervals by people with the authority to act on it. Leadership visibility. Accountability for outcomes.

Diversion mitigation, in most facilities, has none of that — or has it in a fragmented, underfunded, inconsistently executed form that provides the appearance of a program without the substance of one.

The designated owner, if one exists at all, often carries diversion oversight as a fraction of a larger role with competing priorities. The protocols are written but not trained. The monitoring data is generated but not systematically reviewed. The education is annual and compliance-focused rather than ongoing and competency-based. Leadership sees diversion as a pharmacy issue rather than an organizational one.

The result is a program that functions adequately when nothing goes wrong — and fails precisely when it is needed most.

What parity actually requires

Building a diversion mitigation program with the same institutional seriousness as falls prevention does not require a complete rebuild. It requires a shift in how the program is positioned, resourced, and governed.

It requires designated ownership with explicit accountability — a person or team whose primary responsibility includes diversion mitigation, who has the authority to act on what the monitoring data reveals, and who reports to leadership on a regular schedule.

It requires protocols that are trained, not just written — staff who can describe your diversion response process from memory, not just locate the policy in a binder.

It requires data review that is analytical, not ceremonial — someone with the knowledge to examine controlled substance transaction data for patterns, not just confirm that the report was pulled.

It requires leadership visibility — diversion mitigation metrics presented to the same forums that receive patient safety data, with the same expectation of trend analysis and corrective action accountability.

And it requires a cultural shift — from treating diversion as a compliance problem that pharmacy manages to treating it as a patient safety problem that the entire organization owns.

That shift does not happen on its own. It is built — deliberately, over time, through the same kind of sustained institutional commitment that made falls prevention the priority it is today.

At Rxpert Solutions, we work with healthcare organizations to build diversion mitigation programs that operate with the same rigor, the same accountability, and the same institutional seriousness as your highest-priority patient safety initiatives. Because that is exactly what diversion mitigation deserves to be.

If your organization is ready to close the gap between where your diversion mitigation program is and where it needs to be, let’s talk. Your first 30 minutes with Rxpert Solutions are free — and that conversation is the first step toward building a program that actually protects your patients.

— Terri Vidals B.S.Pharm
Founder, Rxpert Solutions | Host, Drug Diversion Insights

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