What Happened
Kelsie Spencer, a nurse at Paul B. Hall Regional Medical Center in Kentucky, stole a controlled substance from the hospital's drug supply for her own use and tampered with the vials to hide it.
While working as a nurse at the hospital, Spencer removed vials of butorphanol tartrate (Stadol), an opioid agonist-antagonist used for pain management, from the drug supply area for personal use. She then injected a saline solution back into the emptied vials so the theft would not be noticed on visual inspection, returning the tampered vials to hospital stock where they remained available for use on patients.
Spencer acknowledged in her plea agreement that she acted with reckless disregard for the risk that another person could be harmed if hospital staff administered the diluted drug to a patient who needed it. She pleaded guilty in July 2019 to tampering with a controlled substance and was sentenced on October 30, 2019, to 24 months in federal prison.
What Went Wrong
A nurse was able to remove and dilute controlled-substance vials from a shared hospital drug supply without early detection. Key failures included:
- No routine potency testing or physical inspection of vials in the drug supply area caught the saline substitution before diluted vials were available for patient use.
- Access to the drug supply area was not limited or logged in a way that flagged an individual nurse's withdrawal pattern for a lower-profile drug like butorphanol.
- No independent verification confirmed that vials returned to stock matched their original fill volume and appearance.
How It Could Have Been Prevented
- Extend diversion monitoring and reconciliation to lower-profile controlled substances like butorphanol, not just high-visibility opioids such as fentanyl.
- Require tamper-evident seals and periodic random potency testing on vials stored in shared drug supply areas.
- Log and audit individual staff access to drug supply areas, benchmarking withdrawal frequency against peers.
- Quarantine and test any vial with signs of resealing or altered fill level before it can be dispensed to a patient.
Related Guidance
- Tough Issues — High-risk scenarios with annotated SQL for analyzing withdrawal-pattern anomalies.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including unusual access to drug supply areas.
- Hospital Diversion Prevention Checklist — Hospital self-assessment, including drug supply area controls.
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) for staff with controlled substance access.