What Happened

An ICU nurse at Parker Adventist Hospital in Parker, Colorado, was found to have been stealing fentanyl from an automated dispensing cabinet assigned to her unit.

The nurse began working in the ICU in January 2018. A routine audit of dispensing-cabinet access and utilization flagged the nurse for unusually high fentanyl "waste" in March 2018. Investigators determined she withdrew fentanyl from dispensing cassettes using a sterile syringe and saline flushes, and on at least some occasions refilled the cassette with saline before returning it to the machine. When interviewed, Sharman tested positive for fentanyl use.

The nurse pleaded guilty to tampering with a consumer product and was sentenced in November 2019 to 44 months in federal prison.

What Went Wrong

  • Waste flagged, but only after the fact. The audit that caught the pattern was a routine monthly report, not a real-time alert — by the time the "red" flag was reviewed, weeks of diversion had already occurred.
  • Cassette-level tampering went undetected at the bedside. A cassette refilled with saline should be catchable through waste witnessing or a weight/volume check, but no such control intercepted it before Sharman herself became the point of failure again.
  • No corroborating behavioral review. High waste alone should trigger a look at attendance, performance, and peer reports — there is no indication that happened before the audit escalated.

How It Could Have Been Prevented

  • Review automated dispensing cabinet discrepancy and waste reports weekly, not monthly, for high-risk units like the ICU.
  • Require a second clinician to witness and co-sign all controlled substance waste at the time it occurs, not after the fact.
  • Correlate high-waste alerts with attendance, behavior, and performance data before dismissing them as clinical variation.
  • Randomly test returned or "wasted" product for potency to catch saline-substitution schemes.

Related Guidance

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