What Happened
Kathleen Noftle, a nurse in the hospice unit at the VA Medical Center campus in Bedford, Massachusetts, diverted morphine meant to ease the suffering of dying veterans under her care.
On January 13, 14, and 15, 2017, Noftle used her position as a hospice nurse to obtain doses of liquid morphine intended for veterans in her care. She mixed tap water from a sink with a portion of each liquid morphine dose, then administered the diluted medication orally to the patients, keeping the undiluted portion she had withheld for herself.
Noftle pleaded guilty in October 2020 to one count of tampering with a consumer product and one count of obtaining a controlled substance by misrepresentation, fraud, deception, and subterfuge. She was sentenced on February 24, 2021, to 40 months in prison and three years of supervised release.
What Went Wrong
Dying, often heavily sedated hospice patients were among the least likely to be able to report inadequate pain control, and no system caught the dilution. Key failures included:
- No potency verification or waste witnessing accompanied liquid morphine doses administered orally in the hospice unit.
- Hospice patients' pain-control status was not independently cross-checked against the nurse's documentation of doses given.
- A single nurse could prepare and administer diluted doses without a second clinician verifying the medication's volume or concentration.
How It Could Have Been Prevented
- Require witnessed preparation and administration of liquid opioid doses in hospice and palliative care units, where patients often cannot self-report inadequate relief.
- Randomly test liquid morphine bottles and prepared doses for potency in hospice settings.
- Independently monitor hospice patients' comfort and pain scores against administration records, escalating discrepancies for review regardless of patient prognosis.
- Apply the same diversion-monitoring rigor to hospice units as to acute-care and ICU settings, rather than treating end-of-life care as lower risk.
Related Guidance
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators including diluted medication and hospice-specific risks.
- Diversion prevention checklist — Self-assessment for hospice medication controls.
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) for staff with controlled substance access.
- Patient Notification After Drug Diversion — When and how to notify potentially exposed patients and families.