What Happened

A nurse at Concord Hospital in New Hampshire pleaded guilty to diverting fentanyl from an intravenous bag connected to an intensive care unit patient who was not under her assigned care.

She removed a quantity of fentanyl from the IV line inserted in the ICU patient and replaced it with saline. She was not assigned to that patient's care as part of her nursing duties, meaning her access to the patient's medication had no clinical justification. She pleaded guilty to one count of tampering with consumer products and faces up to 10 years in prison at a sentencing hearing scheduled for January 2025.

Prosecutors in New Hampshire noted the case as part of a broader pattern of enforcement in the district, alongside civil settlements against hospitals whose recordkeeping failures had enabled other nurses to steal fentanyl undetected for extended periods.

What Went Wrong

  • A nurse was able to access and tamper with a specific patient's IV medication despite not being assigned to that patient's care.
  • Nothing flagged access to a patient's medication line by staff outside that patient's care team for review.
  • An ICU patient's IV fentanyl bag was tampered with without immediate detection, exposing a critically ill patient to inadequate pain control.

How It Could Have Been Prevented

  • Restrict and log access to a patient's IV medication lines to staff actually assigned to that patient's care for the shift.
  • Flag any controlled-substance interaction with a patient by non-assigned staff for immediate review.
  • Use tamper-evident IV bag seals or concentration spot-checks for high-risk medications like fentanyl infusions in the ICU.
  • Train ICU staff to report unexplained presence of non-assigned colleagues near patient medication lines.

Related Guidance

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