What Happened
A registered nurse on the post-operative floor of a Butte, Montana hospital diverted hydromorphone cartridges intended for surgical patients, covering the theft by falsifying waste and administration records.
The nurse worked the post-operation floor of the hospital, where a records review beginning in September 2020 showed she had an abnormally high number of oxycodone and hydromorphone transactions compared to other nurses on the same floor. Rather than administering the withdrawn hydromorphone to patients, she recorded it as "wasted" or documented it as given and then cancelled the order in the electronic system afterward. The hospital placed her on administrative leave after a urine analysis and terminated her four days later when the test came back positive for hydromorphone as well as oxycodone/oxymorphone.
She told investigators she took the hydromorphone to avoid becoming sick when she did not have any of her own drugs on hand, and that she stored the diverted vials in her pocket during shifts. She pleaded guilty in May 2022 to unlawfully obtaining a controlled substance and was sentenced in September 2022 to five years of probation.
What Went Wrong
A nurse was able to falsify waste and cancellation records for months before the pattern was caught. Key failures included:
- Cancelled medication orders were not automatically flagged for review, allowing a nurse to record an administration and then reverse it without scrutiny.
- Transaction-volume outliers among nurses on the same unit were not monitored on an ongoing basis, only discovered after the fact.
- Witnessed wasting of controlled substances was not consistently enforced, letting "waste" entries go unverified by a second clinician.
How It Could Have Been Prevented
- Require a second clinician to witness and co-sign every controlled-substance waste event in real time, not after the fact.
- Flag cancelled or reversed medication administration entries for automatic supervisory review.
- Run periodic peer-comparison reports on controlled-substance transaction volume by unit to surface outliers before they escalate.
- Require for-cause drug testing immediately when transaction anomalies are identified, rather than waiting for a broader review.
Related Guidance
- Hospital Diversion Prevention Checklist — Self-assessment covering surgical-floor controlled-substance controls.
- 15 Red Flags of Drug Diversion — Behavioral and recordkeeping indicators of diversion by clinical staff.
- Waste Documentation Policies — Witnessed waste and documentation requirements for controlled substances.
- Investigation Playbook — Running an internal investigation when diversion is suspected.