What Happened
A former Hilo Medical Center nurse was charged in September 2022 with promoting a dangerous drug and obtaining a controlled substance by fraud, following an investigation into alleged fentanyl theft tied to incidents at the hospital.
Hawaii's State Narcotics Enforcement Division assisted the Hawaii Police Department in investigating the allegations, which involved two incidents at the hospital. She was charged with second-degree promotion of a dangerous drug, third-degree promotion of a dangerous drug, and two counts of obtaining a controlled substance through fraud, deceit, misrepresentation or theft. She pleaded not guilty at arraignment and was released on $55,000 bail, with the case continuing in court.
What Went Wrong
- Public reporting does not specify how the hospital or investigators first identified the alleged fentanyl theft, suggesting detection depended on an outside investigation rather than a documented internal control catching the loss.
- The case involved more than one alleged incident before charges were filed, indicating a pattern rather than a single isolated event.
How It Could Have Been Prevented
- Reconcile fentanyl withdrawals from automated dispensing cabinets against the anesthesia and procedure record for each patient.
- Require immediate reporting of any suspected controlled-substance loss to the hospital's diversion-prevention program and to DEA rather than relying on a law-enforcement referral to surface it.
- Audit waste-witnessing practices for high-risk drugs like fentanyl to ensure two-person verification is actually occurring at the bedside.
Related Guidance
- Hospital Diversion Prevention Checklist — Self-assessment covering controlled-substance accountability.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators of diversion.
- Diversion Case Registry — More documented cases of hospital controlled-substance theft.
- Employee Screening & Fitness for Duty — DEA screening requirements for staff with controlled substance access.