Access to Medication Supply While on Work Leave Contributes to Death

Preventable occurrences of diversion involving methadone and other medications in the hospital setting.

2025 - Volume 25 - ISSUE 1 - SUPPLEMENT 1

Published: February 5, 2025

Bulletin PDF

INTRODUCTION

ISMP Canada previously published a bulletin about the security of methadone in the community pharmacy setting and the death of an individual who gained unauthorized access to the medication in this setting.1 ISMP Canada has learned of additional preventable occurrences of diversion involving methadone and other medications in the hospital setting, including incidents reported by consumers.

INCIDENT DESCRIPTION

Parents shared their concern that their adult child, a hospital employee, had continued to have access to controlled substances at the hospital where they were employed while on a mental health leave. The employee used their staff badge to gain access to methadone, which was then used to end their life.

DISCUSSION AND RESOURCES

A contributing factor in this incident was the employee’s continued access to controlled substances in secure areas of the hospital because their security badge remained active during the period of leave.

Tools developed to support hospitals and other facilities in identifying and reducing the risk of diversion within their organizations include:

Guidance in these resources can support a shift to a culture of safety; the aim is to identify gaps in medication-use systems and to also promote improved wellness support for health care providers.