What Happened
Maria Ann Mihalik, a nurse at Mercy Hospital in Coon Rapids, Minnesota, used a syringe to draw Dilaudid out of patients' IV bags for her own use.
In May 2010, Mihalik entered the hospital and withdrew hydromorphone from IV bags prepared for patients, diverting the drug for herself. She pleaded guilty in March 2011 to one count of obtaining a controlled substance by fraud.
On June 29, 2011, she was sentenced to three years of probation, including 180 days in a halfway house and 150 hours of community service. The Minnesota nursing board separately barred her from practicing nursing in the state.
What Went Wrong
A nurse was able to withdraw medication directly from prepared patient IV bags without the tampering being detected at the point of use. Key failures included:
- Prepared IV bags containing controlled substances were not verified for volume or seal integrity immediately before administration.
- No process flagged a nurse's presence at or access to IV bags outside her assigned patient care duties.
- Diversion was identified only after the fact, rather than through routine reconciliation of dispensed versus administered volumes.
How It Could Have Been Prevented
- Verify weight or volume of prepared controlled-substance IV bags immediately before administration to catch tampering in real time.
- Restrict access to prepared IV bags to the assigned care team for each patient, with access logged and reviewed.
- Reconcile pharmacy-dispensed volumes against administered and wasted volumes on a routine, ongoing basis rather than periodically.
- Report suspected diversion to the state nursing board promptly to prevent continued practice elsewhere.
Related Guidance
- Hospital Diversion Prevention Checklist — Hospital self-assessment covering IV compounding and administration controls.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators of diversion by clinical staff.
- Tough Issues — High-risk scenarios with annotated SQL for analyzing dispense-to-administer gaps.