Exploring the Mechanisms of in-Hospital Emergency Department Diversion: A Qualitative Single-Case Study

Healthcare workers (HCWs) are at risk of substance use disorders (SUD) due to factors such as burnout, stress, and occupational trauma, which may contribute to drug diversion (theft or unauthorized redirection of controlled substances), placing HCWs at risk of overdose, death, professional discipline and legal consequences. Within healthcare settings, workplace social relationships may facilitate access to controlled substances. However, these dynamics are complex, and such relationships may reflect genuine personal, professional, and peer connections rather than solely attempts to obtain controlled substances. This exploratory single case-study design used semi-structured interviews and investigative reports to examine diversion mechanisms. Transcripts were pseudonymized and analyzed thematically to identify diversion mechanisms. Six diversion themes emerged: (1) professional relationships, legitimacy, and forged prescribing practices, (2) professional trust and authority in unauthorized prescriptions, (3) familial relationships and professional acquaintance as concealment, (4) peer relationships and collegial discretion, (5) emergency department (ED) workflow coordination through acquaintanships, and (6) community-based networks with people who use substances (PWUS) and prescription filling. This case illustrates how social connections may facilitate diversion and provides preliminary insights into relational mechanisms that warrant further investigation.