What Happened
Christopher Scott West, a certified registered nurse anesthetist (CRNA) at Floyd County Medical Center in Charles City, Iowa, diverted fentanyl and sufentanil intended for patients in the hospital's surgery and birthing centers.
From February to September 2018, West perforated the tamper-proof seals of fentanyl and sufentanil vials, opened them, withdrew the drugs for his own use, refilled the vials with saline, and glued them shut before returning them to stock. The tampered vials remained available for use in surgical procedures, meaning patients could have received diluted or no anesthetic.
West was sentenced on May 29, 2020, to 34 months in federal prison, a $15,000 fine, $31,998 in restitution, and forfeiture of his two Iowa nursing licenses. The case shows how perioperative access, where providers control both the drug and the documentation, creates one of the highest-risk diversion environments in healthcare.
What Went Wrong
This case illustrates the classic perioperative failure: a single anesthesia provider controls the drug, the syringe, the administration, and the waste record, so self-reconciliation can hide diversion indefinitely. The seven-month duration of the scheme shows that counting alone — without integrity checks of the vials themselves — will not surface saline substitution. Control failures included:
- Anesthesia providers were able to access controlled substance vials without an independent check that the vials returned to stock were intact and unaltered.
- Vial seals were not inspected on return, so perforated, glued vials circulated back into the anesthesia supply.
- Per-case reconciliation (dispense minus administered equals waste) was not performed by pharmacy, so the saline substitution was never caught by counting.
- No peer-comparison surveillance existed to flag a provider whose documented drug use or waste diverged from case norms.
How It Could Have Been Prevented
- Inspect controlled substance vials for seal and content integrity when they are returned to anesthesia storage, and quarantine any vial showing signs of tampering.
- Require closed-loop per-case reconciliation performed by pharmacy: dispensed quantity minus documented administration must equal witnessed waste.
- Enforce two-person waste witnessing with meaningful verification — simultaneous visual confirmation of the wasted volume and destruction.
- Benchmark per-provider drug use and waste rates against anonymous peers, escalating outliers for review.
- Conduct periodic unannounced vial counts and seal checks in anesthesia storage, comparing physical product against the perpetual record.
- Restrict anesthesia access to controlled substances to the minimum needed for current cases, with documented sign-out and sign-in.
Related Guidance
- Anesthesia & OR Drug Diversion: Prevention Strategies — Anesthesia & OR diversion prevention guidance for the perioperative setting.
- Tough Issues — High-risk scenarios with annotated SQL, including perioperative reconciliation and substitution analysis.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including excessive waste and documentation irregularities.
- Hospital Diversion Prevention Checklist — Hospital self-assessment, 8 sections 63 items, including perioperative controls.
- Camera Setup — Placement, retention, and daily obstruction checks for high-risk medication areas.
Sources
- https://www.justice.gov/usao-ndia/pr/charles-city-nurse-anesthetist-sentenced-nearly-three-years-federal-prison-drug
- https://www.beckersasc.com/anesthesia/crna-gets-prison-sentence-15k-fine-for-drug-tampering-in-surgery-birthing-centers
- https://healthcarediversion.org/anesthetist-pleads-guilty-to-stealing-tampering-with-drugs