What Happened

Michelle Kollmar, 56, a registered nurse who treated sickle-cell anemia and cancer comfort-care patients, pleaded guilty to obtaining controlled substances by fraud after diverting hydromorphone intended for patient-controlled analgesia pumps.

Kollmar used patients' identifying information to access an automated medication-dispensing/monitoring system and divert vials of hydromorphone, later returning syringes — some nearly expired, some containing only water — in place of the medication. She accessed the system on some occasions while off duty. Video surveillance captured her diverting and replacing the vials, and she tested positive for hydromorphone she was not prescribed.

Kollmar pleaded guilty on April 24, 2026, to obtaining controlled substances by fraud. Sentencing is scheduled for August 27, 2026, and she faces up to 15 years in prison.

What Went Wrong

A nurse was able to use patient identities to pull medication from a controlled dispensing system, including while off duty, and return water-filled syringes in place of pain medication for some of the hospital's most vulnerable patients. Key failures included:

  • The dispensing system did not flag or block access to controlled substances using patient identifiers by an employee who was off duty at the time.
  • Returned syringes containing only water or that were nearly expired were not caught before being available for administration.
  • No routine checks cross-referenced dispensing-system pulls against actual patient prescriptions and administration records for sickle-cell and comfort-care patients specifically.
  • Detection ultimately relied on video surveillance and a positive drug test rather than dispensing-pattern analytics.

How It Could Have Been Prevented

  • Restrict off-duty access to automated medication-dispensing/monitoring systems and flag any pulls made outside scheduled shifts.
  • Reconcile dispensing-system pulls against patient-specific orders and administration records in near real time, particularly for high-risk drugs like hydromorphone.
  • Physically verify returned or wasted syringes (volume, appearance, weight) rather than accepting visual return alone.
  • Use dispensing analytics to flag employees whose access patterns cluster around specific patient populations without a documented clinical reason.

Related Guidance

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