On August 28, 2022, a paramedic completing a routine daily count of controlled substances on a Brookings Health System ambulance noticed that two vials of fentanyl had an odd appearance. The vials were taken to the hospital pharmacy and locked away until they could be tested. On September 19, 2022, the pharmacy tested the contents with a refractometer and found both vials had been filled with normal saline.
The hospital submitted an incident report to the South Dakota Department of Health on October 17, 2022 and referred the matter to the state Division of Criminal Investigation. Between the discovery and the testing, the pharmacy director and ambulance director conducted routine inventory checks and found no further evidence of tampering. No suspect had been identified, and the criminal investigation remained open at the time of the state survey.
Surveyors learned that the electronic medication safes on the ambulances were ten years old and had their doors removed and sent away for software updates during the period in question. While the doors were out, medications were kept in a keyed cabinet inside each ambulance, and every crew member, including emergency medical technicians, knew where the key was stored. A master key that could override the safes had been kept at the ambulance department where everyone had access to it. Daily counts were performed by a single staff member without a witness, and the hospital had no written policies for medication security in either the ambulance or anesthesia departments.
The state cited the hospital for failing to ensure pharmacy oversight of controlled-substance security and accountability. After the incident, the master key was moved to the nursing supervisor's custody with the other master keys, the remaining safe door update was placed on hold, and the ambulance director or a designated paramedic began performing daily checks on the medications in all four stocked ambulances.