What Happened
Andrea Falzano, an emergency department nurse at a Massachusetts hospital, withdrew opioids from a locked drug cabinet under the names of patients who had already been discharged.
Beginning in May 2019, Falzano used her position in the hospital's emergency department to pull morphine, fentanyl, and hydromorphone — all Schedule II controlled substances — from a locked cabinet. Over an approximately five-month period she made 412 withdrawals tied to 299 patients who had already been discharged and were not receiving the medication she withdrew.
Negative drug tests obtained during the investigation showed Falzano had not actually been using the opioids she reported consuming, undercutting statements she made to her employer and the Massachusetts Board of Registration in Nursing that the theft was an "isolated incident." She pleaded guilty in August 2023 to three counts of unlawfully obtaining controlled substances by fraud, deception, and subterfuge. In November 2023 she was sentenced to three months in prison and one year of supervised release.
What Went Wrong
A single nurse withdrew opioids more than 400 times under discharged patients' names before the scheme was caught. Key failures included:
- Withdrawals were accepted against patient names without confirming those patients were still admitted and eligible to receive the medication.
- No aggregate review flagged one nurse's withdrawal count climbing into the hundreds over a five-month span.
- The hospital and nursing board initially accepted the nurse's self-report of an "isolated incident" without independently verifying it against withdrawal records or drug testing.
How It Could Have Been Prevented
- Cross-check every controlled-substance withdrawal against the patient's active admission status before the withdrawal is authorized.
- Set per-employee withdrawal-volume alerts that flag counts substantially above department peer norms for review.
- Treat withdrawals logged against discharged or transferred patients as an automatic diversion red flag requiring same-day reconciliation.
- Verify self-reported "isolated incident" explanations against full withdrawal history and drug-test results rather than accepting them at face value.
Related Guidance
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators, including high-volume withdrawal patterns.
- Hospital Diversion Prevention Checklist — Hospital self-assessment covering emergency department medication controls.
- Tough Issues — High-risk scenarios with annotated SQL for analyzing dispense-to-administer gaps.
- Diversion Case Registry — More documented healthcare diversion cases.