What Happened
A contract nurse in the pre/post-procedure unit of Novant Health Forsyth Medical Center in Winston-Salem, North Carolina, tampered with sealed vials of injectable hydromorphone, replacing the drug with saline before returning the vials for use on surgical patients.
The nurse was authorized to access an automated medication dispensing/monitoring system in the unit to withdraw controlled substances for patients under a doctor's order. From July through November 2020, she instead opened sealed, tamper-evident container packages of injectable hydromorphone, removed the vials, and injected the drug into herself. To conceal the theft, she refilled the emptied vials with saline solution, reglued the caps, resealed the container packages, and returned them to the locked dispensing system where they remained available to be issued to surgical patients.
She was convicted of tampering with a consumer product and sentenced to 54 months in prison, three years of supervised release, and a $3,000 fine. The case was prosecuted separately from an earlier Virginia federal case against the same nurse for diverting fentanyl and hydromorphone at a different hospital, Sovah Health-Danville, where she was sentenced in March 2022 to 36 months in prison — illustrating how a nurse can divert at more than one employer before being stopped.
What Went Wrong
A nurse was able to reseal tampered vials convincingly enough that they were redistributed to surgical patients rather than being intercepted. Key failures included:
- Resealed container packages and reglued vial caps were not inspected closely enough before redistribution to catch signs of tampering.
- No potency or visual verification process existed to catch a hydromorphone vial that had been diluted with saline before it reached a patient.
- The nurse's prior diversion history at another hospital was not visible to this employer at the time of hiring.
How It Could Have Been Prevented
- Inspect vial seals, caps, and fill levels for signs of tampering — such as glue residue or an uneven seal — before any returned or previously accessed unit re-enters circulation.
- Check state licensing board and prior-employer diversion history as part of credentialing for traveling and contract nursing staff.
- Use tamper-evident packaging paired with random potency spot-checks for high-risk controlled substances like hydromorphone and fentanyl.
- Restrict and audit dispensing-system access logs for patterns of withdrawal that do not match documented patient administration.
Related Guidance
- Hospital Diversion Prevention Checklist — Self-assessment covering surgical-unit controlled-substance controls.
- 15 Red Flags of Drug Diversion — Behavioral and recordkeeping indicators of diversion by clinical staff.
- Audit Witness-Pairing Patterns to Close Waste Documentation Gaps — Detecting patterns behind diverted controlled substances.
- More Diversion Case Studies — Additional documented cases of healthcare drug diversion.