What Happened
Colin Andrew Davis, a paramedic for an emergency air-evacuation company, tampered with fentanyl and ketamine vials carried on medical flights, putting critically injured patients at risk of receiving saline instead of pain medication or anesthesia.
In November 2017, in Weatherford, Oklahoma, Davis removed fentanyl and ketamine from vials and replaced them with a sterile saline solution. A narcotics log later showed that medical professionals had already administered the tampered fentanyl to three patients and the tampered ketamine to one patient before Davis admitted to his employer what he had done. Prosecutors also noted that a life-flight mission had to be canceled because Davis himself was too confused and disoriented, from his own opioid use, to perform his duties.
The U.S. Attorney's Office filed an information in April 2019 charging Davis with tampering with the labeling and container for consumer products, alleging he acted with reckless disregard for the risk that patients would be placed in danger of death or bodily injury. On December 9, 2019, Davis was sentenced to six months in federal prison followed by three years of supervised release.
What Went Wrong
An air-evacuation crew member was able to tamper with emergency narcotics used on active patient flights without detection until self-disclosure. Key failures included:
- No routine testing or visual inspection protocol for narcotics kits restocked after each flight, letting tampered vials re-enter the emergency supply.
- No fitness-for-duty check flagged a crew member who was, by his own admission, too impaired to safely perform his duties before a mission was canceled.
- Narcotics logs were only reviewed retrospectively rather than reconciled against administration records in near real time.
- A single paramedic had unsupervised access to restock and handle controlled substances on ambulance and flight kits between shifts.
How It Could Have Been Prevented
- Require visual and weight/volume checks of narcotics vials before restocking flight and ambulance kits after each shift.
- Implement routine, random fitness-for-duty screening for EMS and flight crew with access to controlled substances.
- Reconcile narcotics administration logs against patient care records within 24 hours rather than after an incident triggers review.
- Require two-person sign-off when restocking or accessing narcotics kits on ambulances and air-evacuation aircraft.
- Train flight and EMS crews to recognize and report peer impairment immediately, with a clear non-punitive reporting channel.
Related Guidance
- Tough Issues — High-risk scenarios with annotated SQL for analyzing dispense-to-administer gaps.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including impairment and documentation irregularities.
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) and pre-employment vetting for staff with controlled substance access.
- Diversion prevention checklist — Self-assessment for ambulance and field narcotics controls.
- Patient Notification After Drug Diversion — When and how to notify potentially exposed patients.