What Happened
Matthew Richard Peterson, a paramedic employed by Allina Health, stole morphine and hydromorphone intended for ambulance patients and replaced the drugs with saline to hide the theft.
From August 2013 to November 2013, Peterson, working as a paramedic, extracted morphine and hydromorphone from ambulance stock with a syringe. To cover up the theft, he replaced the liquid he removed with a saline solution, leaving the vials looking untouched but pharmacologically inert. More than 100 patients were left at greater risk of infection and untreated pain as a result of his tampering.
Peterson was not caught by a routine audit — co-workers discovered the malfeasance, and he only reported himself afterward. He was indicted on August 11, 2014, pleaded guilty on November 7, 2014, and was sentenced on July 16, 2015, to three years of probation for fraudulently acquiring controlled substances.
What Went Wrong
A single paramedic was able to tamper with ambulance narcotic stock for months, exposing more than 100 patients to diluted pain medication, before co-workers — not any inventory control — caught the scheme. Key failures included:
- No routine potency testing or lab verification of ambulance narcotic stock to catch dilution before it reached patients.
- Ambulance drug boxes lacked tamper-evident controls that would have flagged vials that had been opened and resealed.
- Detection depended entirely on informal co-worker observation rather than a structured reconciliation of controlled-substance use against patient care records.
- No mechanism existed to flag a pattern of unusually high "waste" or unaccounted-for narcotics tied to a single paramedic's shifts.
How It Could Have Been Prevented
- Require two-person verification when stocking, wasting, or accessing controlled substances on ambulances.
- Use tamper-evident vial seals or single-use locked pouches for ambulance narcotics, checked at the start and end of every shift.
- Reconcile controlled-substance administration records against patient care reports on a per-shift or per-run basis, not just at periodic audits.
- Randomly sample and lab-test ambulance narcotic stock for potency to catch dilution schemes early.
- Track individual paramedic waste and usage patterns over time to flag statistical outliers for review.
Related Guidance
- Tough Issues — High-risk scenarios with annotated SQL for analyzing dispense-to-administer gaps.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including inventory irregularities.
- Diversion Prevention Checklist — Self-assessment covering controls for controlled substance handling.
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) and pre-employment vetting for staff with controlled substance access.