What Happened
Two pharmacy technicians at Emory University Hospital Midtown in Atlanta illegally ordered and received more than one million doses of controlled substances over nearly five years by misusing their purchasing access and bypassing the pharmacy's receiving and inventory checks.
Between October 2008 and July 2013, the technicians used misappropriated buyer credentials to order alprazolam (Xanax), hydrocodone, and codeine products from the hospital pharmacy's suppliers, then exploited gaps in receiving and inventory procedures to keep the purchases from being reconciled against what was actually delivered to patient care areas. The scheme came to light in July 2013 when hospital staff flagged a suspicious single purchase order placed by one of the technicians.
Emory reported the matter to Emory Police, the Georgia Drugs and Narcotics Agency, and the DEA, and fired both technicians. The Georgia Board of Pharmacy's investigation culminated in a consent order finalized in February 2016 that placed the hospital pharmacy's license on probation for three years, imposed a $200,000 fine, and barred pharmacy technicians from approving orders of controlled substances going forward.
What Went Wrong
A pharmacy purchasing scheme ran for nearly five years and reached over a million doses before it was caught. Key failures included:
- Pharmacy technicians were permitted to approve and receive orders of controlled substances without an independent pharmacist check on each transaction.
- Buyer credentials used to place controlled-substance orders were not adequately restricted or monitored for unusual purchasing patterns.
- Receiving and inventory reconciliation did not catch a sustained mismatch between what was ordered and what was actually needed for patient care.
- No red flag was raised internally until a single suspicious purchase was noticed years into the scheme, rather than through routine audit.
How It Could Have Been Prevented
- Require pharmacist-level approval, independent of the technician placing the order, for every controlled-substance purchase order.
- Restrict buyer credentials for controlled substances to a small, monitored group and audit purchasing activity against patient-level usage on a recurring basis.
- Reconcile received quantities of controlled substances against documented patient administration routinely, not only when a transaction looks unusual.
- Set purchasing-volume thresholds that automatically trigger a compliance review when ordering patterns deviate from historical norms.
Related Guidance
- Hospital Diversion Prevention Checklist — Self-assessment covering pharmacy purchasing and inventory controls.
- 15 Red Flags of Drug Diversion — Behavioral and recordkeeping indicators of diversion by pharmacy staff.
- Why Controlled Substance Count Reconciliation Stops Diversion — Closing the gap between ordered, received, and administered doses.
- Investigation Playbook — Running an internal investigation when a pharmacy purchasing scheme is suspected.