What Happened
A distribution-data review at St. Patrick Hospital in Missoula, Montana, caught a nurse ordering opioids at far higher rates than her peers, and a coworker's separate report confirmed suspicious activity.
In October 2021, a St. Patrick Hospital official reviewing drug distribution data found that Caitlin Ashley Evans was ordering oxycodone, hydromorphone, hydrocodone, and fentanyl in much greater amounts and at much higher rates than her peers. Another nurse independently reported suspicious activity by Evans to a supervisor. When hospital administrators confronted her, Evans admitted she had been diverting drugs from the hospital since the fall of 2020.
Evans explained that she had been taking waste amounts of hydromorphone and morphine two to three times a week, exchanging the diverted drug for saline before disposal to make the waste appear legitimate. She pleaded guilty in November 2022 to obtaining controlled substances by fraud, deception, and subterfuge, and was sentenced in March 2023 to three years of probation.
What Went Wrong
Evans diverted opioids for roughly a year before a routine distribution-data review and a coworker's report ended the scheme. Key failures included:
- Ordering volumes climbed well above peer norms for an extended period before anyone reviewed the distribution data closely enough to notice.
- Waste procedures relied on the diverting nurse's own saline substitution and documentation, with no independent witness verifying that wasted product was actually the controlled substance being discarded.
- A coworker's suspicion of unusual behavior took time to surface through the reporting chain before it converged with the data review.
How It Could Have Been Prevented
- Run automated peer-comparison reports on controlled-substance ordering and withdrawal volumes on a recurring schedule, not only when an anomaly happens to be noticed.
- Require a second clinician to witness and co-sign every controlled-substance waste event, with periodic testing of "wasted" product to confirm it is what was documented.
- Create a clear, confidential channel for staff to report suspected diversion, and track how quickly such reports are escalated and investigated.
- Combine ordering-pattern analytics with waste-documentation audits so either signal alone can trigger a review.
Related Guidance
- Hospital Diversion Prevention Checklist — Self-assessment covering ordering, waste, and audit controls.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators, including above-peer ordering volume.
- Waste Documentation Policies — Witnessed waste requirements for controlled substances.
- Tough Issues — High-risk scenarios with annotated SQL for analyzing peer-deviation patterns.