What Happened
A former nurse at a Dedham, Massachusetts rehabilitation center was sentenced to three years of probation for tampering with liquid oxycodone syringes intended for patients.
Jaclyn McQueen worked as a registered nurse at the rehabilitation center, which provided long-term chronic and post-acute care, and had access to oxycodone prescribed to patients there. From approximately February through May 2020, during her work shifts, McQueen removed liquid oxycodone from syringes intended for patients, consumed the oxycodone herself, and refilled the syringes with water to avoid detection. She returned the diluted syringes to the medication carts, where they could have been administered to patients.
McQueen was charged by information on December 7, 2023, and pleaded guilty in January 2024 to one count of tampering with a consumer product. She was sentenced to three years of probation.
What Went Wrong
A nurse was able to remove oxycodone from prepared syringes and return diluted syringes to shared medication carts for roughly three months before the scheme surfaced. Key failures included:
- Prepared syringes returned to medication carts were not checked for volume or potency, letting water-diluted syringes re-enter circulation for use on patients.
- No witnessed waste process existed for partially used or unused controlled-substance syringes during a shift.
- Access to prepared oxycodone syringes was not restricted or logged closely enough to trace tampering back to a specific shift promptly.
How It Could Have Been Prevented
- Require witnessed waste and documentation for any unused portion of a controlled-substance syringe before it is returned to a shared medication cart.
- Inspect and verify the volume of returned syringes against the prescribed dose before they are made available for administration to another patient.
- Restrict and log which staff access prepared controlled-substance syringes on medication carts, and reconcile against administration records each shift.
- Randomly test returned liquid narcotic syringes for potency to catch water or saline substitution before it reaches a patient.
Related Guidance
- Diversion prevention checklist — Self-assessment covering rehabilitation-center medication cart controls.
- 15 Red Flags of Drug Diversion — Behavioral and recordkeeping indicators of diversion by clinical staff.
- Waste Documentation Policies — Witnessed waste requirements for controlled-substance syringes and vials.
- Signs of Medication Diversion — Recognizing tampering indicators in post-acute and rehabilitation settings.
- More Diversion Case Studies — Additional rehabilitation and long-term care diversion cases.