What Happened
A CDC investigation linked an outbreak of at least 12 hepatitis C infections between August 2017 and March 2018 to Cora Weberg, an emergency department nurse at MultiCare Good Samaritan Hospital in Puyallup, Washington.
Weberg admitted to diverting injectable fentanyl and hydromorphone intended for patients and replacing the drugs with saline. The mechanism of harm was direct: her method exposed patients to her blood through contaminated syringes, transmitting hepatitis C to patients who had no other identifiable risk factor.
The Washington State Nursing Commission revoked her license in 2018. In 2023, Weberg was criminally charged in Washington state in connection with the diversion and the patient exposures. The case remains one of the clearest examples of diversion converting into an infectious-disease outbreak.
What Went Wrong
This case illustrates that the cost of diversion is not measured in lost inventory — it is measured in patient harm. The outbreak was identified through patient infections, not through any medication-handling alert, which means the harm surfaced before the theft did. The control failures included:
- The nurse had routine, unsupervised access to injectable opioids and to the equipment used to prepare and administer them, with no mechanism to link specific syringes to specific patients.
- Administration and waste documentation did not reconcile with actual drug availability, so the saline substitution was not detected at the point of care.
- Diversion surveillance did not flag the pattern for months, even though replacement-with-saline necessarily distorts documented administration and waste volumes.
- No process connected unusual patient outcomes — here, new hepatitis C infections — back to medication handling practices until the CDC investigation did so.
- Because the substitution involved single-dose syringes drawn at the bedside, there was no intact product left behind to inspect; the evidence existed only in documentation that was never reconciled.
How It Could Have Been Prevented
- Enforce witnessed waste and closed-loop reconciliation for every injectable opioid drawn in the emergency department, with pharmacy review of exceptions.
- Use single-dose packaging or syringe-level tracking where feasible so substitution requires breaking an intact, verified unit.
- Benchmark per-nurse administration and waste patterns against peers, escalating outliers for review rather than treating them as routine variance.
- Establish a joint pharmacy–infection-control review pathway so unexplained patient infections are checked against medication handling practices.
- Publicize non-punitive reporting pathways so colleagues can raise concerns about a peer's drug handling or behavior without fear of retaliation.
- Conduct periodic audits of controlled substance access logs against patient census and documented care to surface undocumented access.
Related Guidance
- Tough Issues — High-risk scenarios with annotated SQL, including substitution analysis and multi-dose vial scenarios.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including unexplained losses and pattern-breaking behavior.
- Hospital Diversion Prevention Checklist — Hospital self-assessment, 8 sections 63 items, including administration and waste controls.
- Controlled Substance Inventory Requirements — Biennial inventory practices that surface substitution discrepancies.
- Patient Notification After Drug Diversion — When and how to notify potentially exposed patients and offer bloodborne pathogen testing.