What Happened
Kelsey Mulvey, a registered nurse at Roswell Park Comprehensive Cancer Center in Buffalo, New York, tampered with hydromorphone meant for cancer patients, causing a cluster of waterborne bacterial infections.
Between February and June 2018, Mulvey tampered with and stole controlled medications, including hydromorphone (Dilaudid), from dispensing machines throughout the hospital. She would start a transaction at a dispensing machine, quickly cancel it and leave the medication drawer open, remove the hydromorphone from a vial, replace it with water, and place the vial back into the machine so the total vial count would not trigger scrutiny. She used the patient medical record database to search for patients specifically prescribed hydromorphone, since accessing their profiles was required to reach the dispensing machine's drawer for that drug; at times she diverted vials without administering the medication to any patient at all.
From June to July 2018, six Roswell Park patients became ill with waterborne infections; a hospital investigation traced the outbreak to tampered, compounded hydromorphone vials. Testing found several of the implicated vials had roughly 80 percent of their hydromorphone removed and replaced with contaminated water. Mulvey was placed on administrative leave and resigned in lieu of termination, and pleaded guilty on March 10, 2021, to tampering with a consumer product.
What Went Wrong
A pattern of canceled transactions and unadministered withdrawals went undetected until patients were sickened by contaminated medication. Key failures included:
- Dispensing-machine transactions that were started and then canceled were not flagged or reviewed, even though the drawer was left open during the cancellation.
- No reconciliation matched vials diverted from the machine against actual documented administration to a patient, allowing some vials to disappear with no corresponding dose given.
- Vials refilled with water rather than saline were not caught by any sterility or potency check before being used on patients, resulting in bloodstream infections.
- Patient-record lookups used solely to reach a drug drawer were not audited against the employee's actual clinical assignment to that patient.
How It Could Have Been Prevented
- Flag and review every canceled dispensing-machine transaction where the medication drawer was opened, rather than treating cancellations as routine.
- Reconcile every controlled-substance withdrawal from a dispensing machine against a documented administration or witnessed waste for a specific patient encounter.
- Require sterility and potency testing on compounded vials showing any sign of tampering, especially after unexplained infection clusters.
- Audit staff patient-record lookups against actual care assignments, flagging searches for patients outside the employee's caseload.
- Investigate unexplained infection clusters for a medication-tampering source as part of the standard infection-control workup.
Related Guidance
- Tough Issues — High-risk scenarios with annotated SQL for analyzing canceled-transaction and dispense-to-administer gaps.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including canceled transactions and record lookups outside assignment.
- Hospital Diversion Prevention Checklist — Hospital self-assessment, 8 sections 63 items, including dispensing-cabinet audit controls.
- Patient Notification After Drug Diversion — When and how to notify potentially exposed patients and offer bloodborne pathogen testing.