What Happened
A post-anesthesia care nurse at a hospital in Dodge County, Minnesota, diverted oxycodone from an automated dispensing cabinet by shorting patients' doses and disguising the withdrawals as an unrelated medication.
Jennifer Lee Garrison had access to controlled and uncontrolled substances stored in an automated dispensing cabinet (ADC) on her unit, which held oxycodone alongside oxybutynin, a non-controlled bladder medication. Beginning in August 2022, Garrison began diverting oxycodone pills for her own use. When a patient was prescribed two oxycodone pills, she withdrew both from the ADC but gave the patient only one, keeping the second for herself and falsifying the patient's pain reports to cover the shortfall.
On other occasions, Garrison opened an oxybutynin drawer, removed a pill, then canceled that transaction to make it look like an accidental wrong-drawer access — while the ADC was still unlocked, she opened the oxycodone drawer, took a pill for herself, and gave the patient oxybutynin instead. By July 2023 she was diverting roughly six oxycodone pills a day. She pleaded guilty in May 2024 to one federal count of obtaining a controlled substance by fraud.
What Went Wrong
- ADC transaction cancellations weren't reviewed. Canceled or reversed transactions on the cabinet were not flagged for supervisory review, letting a nurse repeatedly stage a "wrong drawer" cover story undetected.
- Patient-reported pain wasn't cross-checked against dispensing records. Falsified pain reports allowed a pattern of under-dosing to go unnoticed rather than prompting a review of what was actually withdrawn versus administered.
- Two-pill orders weren't reconciled against administration records. Nothing in the workflow caught the repeated gap between pills withdrawn and pills actually given to the patient.
How It Could Have Been Prevented
- Flag and route canceled or reversed ADC transactions for supervisor review, especially when followed immediately by a withdrawal from a different drug's drawer.
- Reconcile quantities withdrawn from the ADC against quantities documented as administered for every controlled-substance order, not just on exception reports.
- Audit patients' pain-management documentation against dispensing logs when a unit shows an unusual pattern of "ineffective" pain relief.
- Restrict ADC overrides and near-simultaneous multi-drawer access, and review access logs for patterns consistent with drawer-switching.
Related Guidance
- Hospital Diversion Prevention Checklist — Self-assessment covering automated dispensing cabinet controls.
- 15 Red Flags of Drug Diversion — Indicators of diversion in dispensing and administration records.
- More Diversion Case Studies — Additional hospital ADC diversion cases.
- Investigation Playbook — Reviewing ADC transaction logs during an internal investigation.