The clearest signs a nurse is stealing drugs show up in three places at once: how the nurse behaves on shift, how controlled-substance records and waste look on paper, and how the nurse appears physically. Any one indicator in isolation usually means nothing. When behavioral changes line up with missing medication, suspicious waste documentation, and patients reporting that their pain medicine isn’t working, the pattern points to diversion rather than ordinary workplace trouble. The CDC has tracked more than a dozen outbreaks of bloodborne infections tied to healthcare worker diversion since the 1980s, which is why catching the pattern early matters.1Centers for Disease Control and Prevention. Clinician Brief: Drug Diversion
Behavior and Work Pattern Changes
The earliest signals are rarely about medication at all. A nurse who is diverting often becomes withdrawn, pulls away from coworkers, and avoids social interaction during shifts. Mood swings, irritability, and sudden personality changes are common. So is becoming defensive when questioned about errors or blaming others for mistakes.
Shift patterns tell their own story. Volunteering repeatedly for extra shifts, especially on units that use heavy amounts of controlled substances, is a classic red flag. Arriving late, leaving abruptly, disappearing for long breaks, or burning through sick days all fit. Some nurses angle to care for patients who need pain medication or offer to give narcotics to a colleague’s patient, maneuvering themselves into repeated access to controlled drugs. On its own, any one of these is noise. Stacked, they form a pattern that deserves attention.
Medication Handling and Waste Red Flags
This is where diversion actually happens, and the signs are more concrete. Common methods include stealing syringes or vials outright, under-dosing patients and keeping the remainder, replacing a controlled substance with saline or another look-alike liquid, pulling duplicate doses, creating false verbal orders, and pulling medication out of sharps containers.2Centers for Medicare & Medicaid Services. Drug Diversion: What Is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs?
Waste manipulation is easier to spot than most schemes once you know what you’re looking at. Watch for a nurse who:
- Frequently reports “spilling” or “dropping” controlled substances.
- Discards what looks like a full dose when only part should remain.
- Repeatedly asks the same coworker to co-sign waste the coworker never actually witnessed.
- Holds waste until the end of a shift instead of disposing of it immediately, which creates time to pocket the drug and substitute something else.
The strongest documentation-based signal is a straightforward discrepancy: medication the system says was dispensed, patients who say they never received it. When patients consistently complain that their pain medication isn’t working, or report that a dose the chart says was given never actually arrived, that pattern points to diversion rather than ordinary charting error.
Charting and Dispensing Cabinet Patterns
Charting irregularities leave a paper trail, which is what makes them reliable. A nurse who charts medication administration before giving the drug, over-documents patient pain levels to justify pulling more narcotics, or shows frequent inconsistencies between narcotic records and patient charts is generating the kind of evidence that audits catch.
Automated dispensing cabinets add a digital trail. A few patterns stand out:
- Override removals. Overrides let a nurse pull medication before a pharmacist reviews the order, which exists for genuine emergencies. A nurse who racks up overrides at an unusual rate is generating a red flag that pharmacy review should catch.3Institute for Safe Medication Practices. Guidelines for the Safe Use of Automated Dispensing Cabinets
- Pulls without a matching order. Medications removed without a corresponding physician order, or without a documented administration in the patient’s record, are early identifiers of a problem.4Department of Veterans Affairs Office of Inspector General. Pharmacy Automated Dispensing Cabinets Need Improved Monitoring for Accountability over High-Risk Medications
- Off-pattern access. Cabinet access after hours, or for patients not assigned to the nurse.
- Canceled and retried transactions. A nurse starts to withdraw a drug, cancels, and tries again under different parameters.
- Generic login use. Medications removed under a generic login rather than tied to a specific patient profile.
- Mismatched quantities. The amount pulled doesn’t match the amount ordered.
A 2025 VA Inspector General review found that 121 of 137 local facility policies failed to include a process for monitoring removals made without a patient’s name, a gap that directly raises diversion risk.4Department of Veterans Affairs Office of Inspector General. Pharmacy Automated Dispensing Cabinets Need Improved Monitoring for Accountability over High-Risk Medications If override reports and unassigned-patient pulls aren’t being reviewed, the digital signs sit in the system unseen.
Physical and Health Signs
Physical indicators in a nurse who is using diverted drugs mirror what you’d see in anyone misusing opioids or other controlled substances: constricted or dilated pupils, slurred speech, an unsteady walk, tremors, or excessive sweating. Deteriorating personal appearance is common, including poor hygiene, noticeable weight changes, or showing up disheveled. Some nurses who inject diverted drugs wear long sleeves in warm weather to cover needle marks.
Emotional changes often ride along with the physical ones. Anxiety, depression, emotional flatness, forgetfulness, or swings between drowsiness and euphoria can all point to active substance use. None of this is unique to diversion. Plenty of health conditions produce overlapping symptoms. But when physical changes appear alongside medication discrepancies and the behavioral shifts above, the combination is hard to explain away.
Why the Signs Matter for Patients
Diversion isn’t a victimless workplace problem. Patients whose medication is stolen or diluted suffer twice: they don’t get the pain relief they need, and they can be exposed to contaminated substances carrying serious infection risk.
When a nurse replaces an injectable opioid with saline and reinjects into a vial using the same syringe, any bloodborne pathogen the nurse carries can transfer to the next patient who receives medication from that vial. In a 2018 Washington state case, a single emergency department nurse who admitted to diverting injectable narcotics was linked to at least 12 hepatitis C infections among patients. Neither the first nor second identified patient had any behavioral risk factor for hepatitis C; the virus came from the nurse’s contaminated syringes.5Centers for Disease Control and Prevention. Hepatitis C Virus Potentially Transmitted by Opioid Drug Diversion from a Nurse – Washington, August 2017-March 2018 The nurse had worked only about seven months, but the facility had to notify nearly 3,000 patients who had received injectable drugs during that period. The CDC’s outbreak table lists more than a dozen similar incidents going back to 1983.1Centers for Disease Control and Prevention. Clinician Brief: Drug Diversion
What to Do if You Suspect Diversion
If you’re a coworker, supervisor, or administrator and the signs are stacking up, the worst move is doing nothing. Silence keeps patients at risk, exposes the facility to liability, and delays help for a nurse who may be in the grip of a substance use disorder.
Document what you’ve seen with specifics: dates, times, medication names, patient complaints, and charting inconsistencies. Report to your nurse manager or the facility’s compliance department. Most hospitals have a drug diversion response team or a designated chain of reporting. Don’t confront the nurse directly. It can compromise an investigation and gives the person time to cover tracks.
Facilities that confirm diversion have federal obligations. Theft or significant loss of controlled substances must be reported to the DEA using form DEA-106.6U.S. Drug Enforcement Administration. Chemical and Drug Theft/Loss Reporting CMS guidance further recommends notifying the U.S. Department of Health and Human Services Office of Inspector General and local law enforcement.7Centers for Medicare & Medicaid Services. What Is a Prescriber’s Role in Preventing the Diversion of Prescription Drugs? If patients may have received contaminated injections, the facility also has to start patient notification and testing. Delay on that step is what turns a diversion case into a public health disaster.