What Happened
Elizabeth Prophitt, a certified registered nurse anesthetist working as a surgical nurse at the Ann Arbor VA hospital, stole more than 2,000 vials of controlled substances from hospital dispensing machines.
Prophitt used her position to steal Schedule II and Schedule IV controlled substances — including fentanyl, hydromorphone, morphine, and midazolam — from hospital automated dispensing machines. To obtain the drugs, she used protected patient information and falsified medical documents to make the withdrawals appear legitimate, drawing on records for surgical patients who were not actually receiving the medication she withdrew.
Prophitt was sentenced by U.S. District Court Judge Robert H. Cleland after pleading guilty to five counts of obtaining controlled substances by fraud, misrepresentation, or deceit. On November 9, 2021, she was sentenced to three years of probation.
What Went Wrong
A theft of more than 2,000 vials over time points to a large, sustained gap in dispensing-machine oversight. Key failures included:
- Falsified medical documentation was accepted to justify controlled-substance withdrawals without independent verification against the actual surgical schedule.
- No aggregate audit flagged a single surgical nurse's dispensing-machine withdrawal volume climbing into the thousands of vials over time.
- Patient records were accessible for use in justifying withdrawals without cross-checking that the named patient was actually in a procedure requiring that medication at that time.
How It Could Have Been Prevented
- Cross-reference every dispensing-machine controlled-substance withdrawal against the live surgical schedule and anesthesia record before release.
- Set aggregate withdrawal-volume alerts per staff member, escalating automatically when cumulative withdrawals exceed peer norms.
- Audit falsified or altered medical documentation patterns as a distinct diversion red flag, not just individual transaction anomalies.
- Require periodic reconciliation of dispensing-machine records against actual controlled-substance administration charted in the anesthesia record.
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 high-volume withdrawal patterns.
- Hospital Diversion Prevention Checklist — Hospital self-assessment covering surgical and anesthesia medication controls.
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) for staff with controlled substance access.