What Happened

A registered nurse at Yale New Haven Hospital pleaded guilty to tampering with and stealing vials of lorazepam from the hospital's secure controlled-substance storage.

As part of his job, he had access to secure locations where the hospital stored controlled substances, including lorazepam. He removed a portion of the lorazepam solution from at least one vial that he knew was intended for dispensing to patients, replaced the missing volume with an inert solution, and returned the tampered vial to the secure storage location where it remained available for use on a patient. He also kept at least one vial he had taken outright.

He pleaded guilty to one count of tampering with a consumer product and one count of acquiring a controlled substance by fraud, misrepresentation, or subterfuge. His nursing license was suspended following the plea, and sentencing was scheduled for March 2025.

What Went Wrong

  • A tampered vial returned to secure storage after removal of some of its contents was not detected before it could have reached a patient.
  • Access to secure controlled-substance storage was not paired with any mechanism to verify that returned or handled vials still contained the labeled concentration.
  • The diversion surfaced only through investigation after the fact rather than through routine inventory or potency verification.

How It Could Have Been Prevented

  • Require witnessed handling and immediate reconciliation whenever a controlled-substance vial is removed from and returned to secure storage.
  • Periodically test vials pulled from secure storage for potency, particularly for high-diversion-risk drugs like benzodiazepines and opioids.
  • Track and audit individual staff access patterns to secure storage locations, flagging unusual frequency or timing.
  • Move quickly to restrict system and secure-storage access whenever a staff member's controlled-substance handling comes under suspicion.

Related Guidance

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