Diversion of controlled substances: a catalyst for change.

A quality improvement team was formed in response to a controlled substance diversion by an employee. The team's objectives were to track controlled substances throughout the institution and to design a system that would eliminate inappropriate access to controlled substances without negatively affecting patient care. The team utilized flow charts, staff interviews, and auditing tools to identify weaknesses within the current system. Subcommittees were formed to evaluate access and to develop an education campaign. It is the institution's responsibility to keep patients and staff safe by designing, implementing, and monitoring systems to appropriately control access to controlled substances.