What Happened

From January 2022 to March 2023, registered nurse Christina Eileen Olson diverted narcotics from at least 50 new mothers on a labor and delivery unit at a Waterloo, Iowa hospital. Using her nursing credentials, she diverted fentanyl, morphine, hydromorphone, and oxycodone intended for laboring and post-partum patients, replaced fentanyl in a vial with saline, and falsified medication administration records to conceal the diversion.

The diversion ran for more than a year before it was uncovered. Olson pleaded guilty to acquiring a controlled substance by fraud, adulteration and misbranding of a drug, and making false statements. She was sentenced to one year and one day in federal prison followed by three years of supervised release, and her nursing license was forfeited.

The case is a stark example of diversion from a vulnerable patient population: laboring and post-partum patients whose pain medication was removed, diluted, or replaced at the point of care, with falsified records used to make the administered doses appear legitimate.

What Went Wrong

The multi-month duration of the scheme points to several breakdowns in the labor and delivery medication workflow:

  • A single nurse controlled both the administration of controlled substances and the medication administration records, and the falsified entries were not caught by routine chart review for more than a year.
  • Replacing fentanyl in a vial with saline suggests returned or partially used vials were not subjected to any integrity check before reuse.
  • Documented administration was accepted at face value, with no independent audit correlating doses charted with patient outcomes, vial counts, or waste documentation.
  • Waste and partial-dose handling were apparently not witnessed or verified, allowing the nurse to chart disposal that did not occur.
  • No usage benchmarking existed for the unit, so an individual clinician's elevated draw rate for fentanyl, morphine, hydromorphone, and oxycodone did not generate an alert over the 14-month window.

How It Could Have Been Prevented

  • Require two-person witnessing of all controlled substance waste and partial-dose disposal on labor and delivery, with supervisor co-sign for any exception.
  • Conduct routine audits of medication administration records against vial counts and patient records, escalating discrepancies within a defined timeframe.
  • Verify the integrity of any vial or package returned to stock, and quarantine units with evidence of tampering for investigation.
  • Benchmark controlled substance usage per clinician against unit peers and alert on sustained outliers.
  • Correlate charted doses with patient-reported pain scores and outcomes as a diversion signal rather than accepting documentation at face value.

Related Guidance

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