What Happened
Marlene Gilmore, a nurse at North Colorado Medical Center in Greeley, stole fentanyl, morphine, and hydromorphone from the hospital's locked automated medication management system and used the drugs while on the job.
In 2016, Gilmore accessed the hospital's locked automated dispensing system and diverted fentanyl, morphine, and hydromorphone intended for patients. Evidence in the case showed that she used the diverted drugs while she was on duty at the hospital. She pleaded guilty to one count of theft of a controlled substance by deception.
On April 26, 2018, Gilmore was sentenced to four months in federal prison followed by one year of supervised release. The case was investigated by the FDA Office of Criminal Investigations and announced the same week as a similar case against another Colorado nurse who was sentenced for diverting opioids from a Denver VA hospital and a UCHealth emergency room.
What Went Wrong
A nurse was able to divert opioids from a locked dispensing system and use them while working a clinical shift before the theft was uncovered. Key failures included:
- Access to the automated medication management system was not paired with monitoring sufficient to flag a pattern of withdrawals inconsistent with the nurse's assigned patients.
- No workplace-impairment detection process identified that a staff member was using diverted opioids while on duty, allowing the scheme to continue undetected.
- Discrepancies between what was withdrawn from the locked system and what was documented as administered to patients were not caught in real time.
How It Could Have Been Prevented
- Reconcile every controlled-substance withdrawal from an automated dispensing system against a documented administration or witnessed waste for a specific patient, flagging mismatches promptly.
- Train charge nurses and supervisors to recognize and act on signs of on-the-job impairment, with a clear, non-punitive reporting pathway.
- Benchmark individual withdrawal frequency and volume against unit peers, and investigate outliers before a pattern becomes prolonged.
- Run for-cause and random drug screening for staff with access to controlled substances when discrepancies or impairment concerns arise.
Related Guidance
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including on-duty impairment and unexplained withdrawal patterns.
- Hospital Diversion Prevention Checklist — Hospital self-assessment, 8 sections 63 items, including dispensing-cabinet reconciliation controls.
- Analytics Dashboard Guide — Analytics KPIs and benchmarks for peer-comparison surveillance of dispensing activity.