Catching the Diversion Your Software Is Not Built to SeeCatching the Diversion Your Software Is Not Built to See
Drug Diversion Insights with Terri Vidals
Terri Vidals talks with pharmacist leader Deepika Nayar about building a standardised drug diversion prevention programme across a large, varied health system. The discussion focuses on assessments, shared governance, inpatient versus outpatient differences and the limits of current diversion software.
34:08•22 Jul 2026
Building a Unified Drug Diversion Programme Across 17 Hospitals
Episode Overview
- Start with a thorough assessment of each site’s current diversion monitoring, investigation and reporting practices before designing a standard programme.
- Create shared governance with risk, compliance, HR, nursing and pharmacy leadership to set non-negotiable standards while allowing local flexibility.
- Recognise key differences between inpatient and outpatient workflows and adapt controls, such as inventory checks, dual sign-off and camera surveillance, accordingly.
- Use data on inventory changes, voided transactions and matrix drawer access to spot patterns rather than relying only on single incidents.
- Engage frontline staff, including nurses and patients, to understand practical barriers, check whether policies work and strengthen the overall safety culture.
“Variation is going to be there. But the end state is harmonisation.”
What drives someone to seek a safer, more consistent approach to handling controlled and high-risk medicines across dozens of healthcare sites? This conversation between pharmacist host Terri Vidals and guest Deepika Nayar sheds light on exactly that challenge. Deepika, Network Manager of Pharmacy Quality, Compliance, and Accreditation at Hackensack Meridian Health, explains how she was hired for regulatory compliance and quickly realised every site had its own way of tackling drug diversion.
As she puts it, key stakeholders saw “we don’t have a harmonised diversion prevention programme”, so she set out to build one across 17 hospitals, infusion centres and a growing number of retail pharmacies. You’ll hear how she started with a comprehensive assessment at each site: what was being monitored, how investigations were handled, and whether there was any formal process at all.
From there, she pulled together risk, compliance, HR, nursing leadership and pharmacy directors to create shared governance, a charter, a steering committee and local response teams, all while respecting different workflows and resources. Deepika breaks down the contrasts between inpatient and outpatient settings, from dual sign-off on ordering and stocking to the realities of counting tablets in hospital versus large quantities in retail.
She talks about manual and software-based monitoring, including camera surveillance, pattern spotting in inventory overrides, and the struggle to catch diversion of non-controlled medicines with limited tools. One standout idea is her focus on culture: explaining the “why”, listening to frontline staff, and checking whether policies actually work in real life. Her reminder that “variation is going to be there. But the end state is harmonisation” sums up the practical, team-centred tone of the episode.
If you’re juggling multiple sites and want safer, smarter drug diversion controls without drowning staff in extra work, could Deepika’s system-wide approach point you in a new direction?
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