Gaps in implementation of controlled substance diversion prevention safeguards: A cross-sectional study of hospitals in Ontario, Canada

PURPOSE: Drug diversion, defined as the theft or loss of opioids and other controlled substances (CS), is a persistent concern in hospitals, threatening patient safety, staff well-being, and public trust. Despite rising CS losses in hospitals, the implementation of hospital safeguards remains poorly characterized. This study examined diversion prevention practices and identified gaps in hospital practice. SUMMARY: A cross-sectional study of hospitals in Ontario, Canada, was conducted using an online self-assessment tool for diversion risks, hosted by the Institute for Safe Medication Practices Canada. Participating hospitals rated their implementation of 61 diversion safeguards on a 5-point scale, from 0 (not implemented) to 4 (used more than 90% of the time), grouped into 7 domains. Between May 2022 and October 2025, 36 hospitals completed the assessment. Substantial vulnerabilities were identified across multiple domains. The lowest mean scores were observed in the auditing domain (mean of 1.5), where a high percentage of hospitals reported rarely or never implementing key safeguards, including 83% for audits of anomalous prescribing, 78% for audits of CS waste, 75% for anonymous reporting mechanisms, and 78% for timely investigation of reports. The governance and education domain also had low scores for implementation (mean of 2.1), with similarly high percentages of hospitals reporting rarely or never implementing staff diversion prevention education (89%) and interprofessional diversion response teams (69%). CONCLUSION: Critical gaps exist in the implementation of auditing, governance, and education safeguards for CS diversion in hospitals, with key safeguards rarely or never implemented in 69% to 89% of hospitals despite regulatory and accreditation standards.