In October 2022, Kaiser Permanente implemented a process called Control Check to investigate unresolved discrepancies related to controlled substances. This program integrates data from KP HealthConnect and Pyxis to reconcile dispenses, administrations, wastes, and returns. As part of this initiative, all staff with access to controlled substances are required to complete education on medication diversion, including relevant policies and procedures.

Initially, the medical center faced a significant number of open variances, approximately 30 to 40 daily, primarily due to incomplete documentation. These unresolved discrepancies posed a potential risk for diversion.

A turning point came in July 2025, when the center began reporting weekly variance data during the daily safety huddle. Under the guidance of new nursing leadership committed to fostering a culture of safety and quality, a directive was issued: all open variances must be resolved within 24 hours.

Over the following 2–3 months, nursing managers worked intensively with pharmacy and frontline staff to address each open variance. Thanks to this collaborative effort, we successfully achieved our goal of zero open variances. This success has been sustained for months, reflecting the dedication and hard work of nursing staff and managers, along with strong support from nursing leadership.