What Happened
The Assistant Director of Nursing at a Chicago-area medical rehabilitation center pleaded guilty to tampering with liquid morphine prescribed to at least five patients so she could keep the withheld drug for herself.
Sarah Diamond was responsible for dispensing patient medications at the rehabilitation center. In July and August 2021, she removed morphine from bottles prescribed to patients and replaced it with another liquid, knowing the diluted substance would be dispensed to those patients. Two of the diluted bottles were later found to contain only about 26 percent and 53 percent of their declared morphine content. Diamond then administered the diluted doses to the patients — each of whom had been prescribed liquid morphine to manage their pain — while withholding the remainder for her own use.
Diamond pleaded guilty in April 2023 to one count of tampering with a consumer product, facing a maximum of ten years in federal prison. At the time of her plea, a sentencing date had not yet been scheduled.
What Went Wrong
A single staff member responsible for dispensing medication was able to dilute liquid morphine for at least five patients over a two-month span before detection. Key failures included:
- No routine volume or potency verification of liquid morphine bottles caught doses that had been diluted to as little as 26 percent of their declared strength.
- A single director-level nurse combined medication-dispensing duties with a supervisory role, reducing independent oversight of her own dispensing activity.
- Patients receiving under-strength pain medication over multiple doses were not identified through pain-management monitoring as a possible tampering signal.
How It Could Have Been Prevented
- Require a second staff member to independently verify liquid morphine volume or weight at the time of dispensing, especially when the dispensing nurse also holds a supervisory role.
- Randomly sample liquid controlled substances for potency testing to catch dilution before it reaches multiple patients.
- Monitor patients on scheduled liquid opioids for unexplained changes in reported pain control as a possible diversion indicator.
- Separate medication-dispensing authority from supervisory or directorial roles so no single employee's activity goes unchecked.
Related Guidance
- Diversion prevention checklist — Self-assessment covering rehabilitation-center medication dispensing controls.
- 15 Red Flags of Drug Diversion — Behavioral and recordkeeping indicators of diversion by clinical staff.
- Patient Complaints: An Overlooked Signal in Diversion Detection — Using unresolved pain complaints to flag possible tampering.
- Waste Documentation Policies — Witnessed waste and documentation requirements for controlled substances.
- More Diversion Case Studies — Additional rehabilitation and long-term care diversion cases.