Image by MasterTux from PixabayDrug diversion in ambulatory surgery centers (ASCs) is more common than most operators realize.
And the consequences of not taking the topic seriously are far-reaching.
Although the Drug Enforcement Agency (DEA) inspects ASCs less commonly than hospitals, that doesn’t mean these facilities are off the hook, Dennis Wichern, a retired DEA agent and partner at Prescription Drug Consulting, said during a recent Ambulatory Surgery Center Association (ASCA) webinar.
“The odds of DEA knocking on the door of your ASC are probably about one in a thousand,” he said. “But that doesn’t mean you’re not vulnerable.”
In fact, ASCs are particularly vulnerable due to limited oversight, outdated processes and staffing models that rely heavily on trust and informal controls.
Why the ASC setting makes diversion easier
Alex Yampolsky, CEO of MedServe, echoed Wichern’s concerns, pointing to gaps in the medication management process that leave ASCs exposed.
MedServe provides digital medication management solutions, primarily focusing on secure storage and tracking of controlled substances for health care facilities.
Unlike hospitals, ASCs often don’t have full-time pharmacists or advanced medication management systems in place, Yampolsky said. Instead, the same small team of nurses and clinicians may be responsible for ordering, administering, documenting and wasting controlled substances.
That structure increases the likelihood that a single staff member can divert drugs without detection, Yampolsky said.
“There’s no pharmacy overseeing the medication chain,” Yampolsky said. “It’s often a nurse who orders the drugs, stocks them, administers them and documents it all. That kind of workflow, without separation of duties, makes it easy for something to go wrong.”
Wichern added that while DEA attention is often focused elsewhere, ASCs are still legally responsible for tracking, storing and securing controlled substances.
“DEA’s sole authority is the record-keeping and security of pharmaceutical controlled substances,” Wichern said. “That’s what they care about when it comes to ASCs.”
How diversion happens
In many cases, a nurse or anesthesia provider will remove part of a dose for personal use and either forge the waste documentation or refill the vial with saline before returning it to inventory, Wichern said, adding that most common diversion involves opioids like fentanyl and morphine.
And paper logs make it especially easy to manipulate records, as signatures can be forged and timelines obscured, he added.
According to Yampolsky, some diversion takes place long before medication is administered. He cited examples in which medications were ordered through separate channels and never logged properly.
In other cases, drugs were delivered but left unsecured for hours or even days before being checked into inventory.
Once inside the facility, those drugs are typically stored in double-lock cabinets, but the safeguards are often weak.
“Everyone knows the code to the cabinet, or the keys are stored in a lockbox that hasn’t had the code changed in a year,” Yampolsky said. “It’s a system built on trust, not accountability.”
High stakes for staff, patients
Both experts emphasized that drug diversion doesn’t just impact inventory.
It compromises patient safety, erodes team culture, and puts the individual diverting the drugs at extreme personal and legal risk.
“It seems like a number of the overdoses in hospitals and the few ASCs happen after somebody leaves the surgery, and they go immediately to the bathroom to inject the drugs that they somehow diverted from the vial,” Wichern said.
The emotional toll on staff can be severe, Yampolsky said.
“Most people don’t set out to be thieves,” he said. “They’re good people who end up in a moment of weakness, often because of stress or substance use disorder. But once they cross that line, it’s very hard to come back. Lives are ruined. Sometimes people end up in jail. Sometimes they end up dead.”
And yet, many cases are never reported, because facilities fear reputational damage or triggering a DEA investigation.
“Diversion is underreported not because it’s rare, but because no one wants their name in the news,” Yampolsky said.
Where the gaps are
According to Wichern, ASCs must maintain records for at least two years and ensure those records are readily available in case of an audit. Operators are required to keep purchase invoices, DEA Form 222s, dispensing and wasting documentation, and any reports of theft or loss. And every location where controlled substances are stored must be registered separately.
But simply having policies isn’t enough, he said.
“Nowhere in the DEA regulations does it say you must have written policies,” he said. “But when something goes wrong, the first question people ask is, ‘What was your policy?’ You better have one, and you better be following it.”
There is a need for digital systems that restrict access to only the medications a provider is authorized to use, Yampolsky said.
“What matters is how it’s used,” he said. “You need processes in place so that no one is ever the only person involved in ordering, receiving, stocking or wasting drugs. And wasting should happen immediately after administration, in front of a witness.”
As the ASC industry grows and more surgical volume shifts to the outpatient setting, the gaps in medication security are becoming more visible. Former hospital staff, now working in ASCs, are often the ones raising red flags about insufficient systems and oversight.
“This is a big problem, and it’s getting more attention,” Yampolsky said. “People who work in ASCs know it’s happening, but it’s not talked about publicly nearly enough.”
Taking action doesn’t have to be expensive or overly complicated, Wichern said.
“Common sense goes a long way,” he said. “Lock your drugs. Track your records. Use the rule of two. And if you’re not sure what’s required, get help.”
