Diversion Case Studies

Anesthesiologist placed on probation after being sanctioned for abusing fentanyl and Demerol

Los Angeles, CA

A licensed anesthesiologist was sanctioned by the Arizona Medical Board after being found to have abused fentanyl and Demerol, both controlled substances used in anesthesiology practice. The Maryland Board of Physicians imposed reciprocal discipline, placing the physician on five years of probation subject to terms and conditions.

Rochester nurse admitted diverting morphine and hydromorphone through fraudulent dispensing-cabinet entries

A Rochester, New York, nurse holding both registered and practical nurse licenses admitted to diverting morphine and/or Dilaudid for her own use by making fraudulent entries in an automated dispensing cabinet under patient identification numbers. In several instances there was no physician order for the narcotics withdrawn. On November 9, 2001, the Board of Regents accepted a consent order imposing a suspension of at least six months and until terminated as set out in the order, followed by two years of probation upon return to practice and a $500 fine.

Physician assistant self-prescribed narcotic analgesics and benzodiazepines while addicted to opiates

Baltimore, MD

A physician assistant was found by the Maryland Board to have filled prescriptions for himself for narcotic analgesics and benzodiazepines while struggling with opiate dependency. The Board found him guilty of providing professional services while using a controlled substance and of unprofessional conduct in the practice of medicine. He received a three-year suspension, with all but ten months stayed, followed by five years of probation.

Physician assistant applicant found guilty by court-martial of self-prescribing controlled substances and prescribing them for his spouse without authorization

Virginia Beach, VA

A physician assistant applicant was found guilty by a Navy court-martial of self-prescribing controlled dangerous substances and prescribing them for his spouse without authorization. The Maryland board denied his application for physician assistant certification based on this record, along with unrelated findings in the same proceeding.

New York practical nurse surrendered license after admitting diversion of Fioricet for personal use

A licensed practical nurse from Rome, New York, applied to surrender her license after admitting to a charge of diverting the controlled drug Fioricet for her own use. The New York State Board of Regents granted the surrender application on November 5, 1999. The published summary does not describe the workplace or how the diversion came to light.

Psychiatrist in Salisbury, MD, reprimanded for writing controlled dangerous substance prescriptions for himself under others' names

Salisbury, MD

A psychiatrist received a reprimand and four years of terms and conditions. The Board reported that the physician wrote prescriptions for controlled dangerous substances for himself in the names of others and issued undated CDS for patients. The action was dated August 25, 1999.

Family practice physician convicted of illegally distributing stimulants and dispensing controlled substances

Potomac, MD

A family practice physician was convicted in circuit court of fifteen counts of distribution of stimulants and seven counts of unlawful dispensing of a controlled substance. The conviction was affirmed on appeal. Because state statute required revocation following this criminal conviction, the medical board revoked the physician's license.

Registered nurse misappropriated controlled substances at Mountainside Hospital

A consent order suspended a registered nurse's license indefinitely on September 1, 1995. The stated basis included findings that the nurse misappropriated controlled substances for personal use from December 1994 through April 1995 while employed at Mountainside Hospital.

Mooresville pharmacist's license suspended indefinitely for unauthorized consumption of controlled substances

Mooresville, NC

The Board reported that a pharmacist in Mooresville consumed controlled substances without authorization. A previously stayed indefinite suspension was terminated, and the license to practice was suspended indefinitely.

Graham pharmacist's license suspended indefinitely for obtaining and consuming controlled substances without authorization

Graham, NC

The Board reported that a pharmacist in Graham obtained and consumed controlled substances without authorization. The license to practice pharmacy was suspended indefinitely.

Pharmacist at Fairview Pharmacy Consultants obtained and consumed controlled substances without authorization

Fairview, NC

The North Carolina Board of Pharmacy reported that a pharmacist at Fairview Pharmacy Consultants in Fairview obtained and consumed controlled substances without authorization. The pharmacist's license was suspended indefinitely, with the suspension stayed for five years under conditions.

Arkansas hospital nurse's license suspended three years after narcotics cabinet tampering and Demerol concerns

The Arkansas State Board of Nursing charged a registered nurse under the state nursing practice act with being habitually intemperate or addicted to habit-forming drugs and with unprofessional conduct, based on events at a Bentonville hospital and a Eureka Springs hospital in 1992. After a hearing in August 1993 the Board suspended the nurse's license for three years with conditions on reinstatement. The circuit court affirmed, and in April 1995 the Arkansas Supreme Court held the Board's decision was supported by substantial evidence.

Registered nurse misappropriated controlled substances at Montclair Community Hospital

A registered nurse's license was suspended for two years on October 12, 1991. The stated basis was misappropriation of controlled substances during February and March 1991 while employed at Montclair Community Hospital.

University of Utah Medical Center nurse accused of diverting Percocet by substituting Tylenol

A nurse at University of Utah Medical Center was accused in a petition filed with the state Division of Occupational and Professional Licensing of diverting Percocet for her own use. The petition alleged she signed out Percocet prescribed to patients who had been discharged and had not requested it, and on about 10 occasions substituted plain Tylenol or Tylenol and Motrin combinations to women who had requested Percocet while keeping the Percocet. It also alleged she began taking one to three pills a week away from work and later used Percocet at work; she voluntarily entered a drug dependency program. The division charged her with two counts of violating the state's Nurse Practice Act and Controlled Substance Act, and she faced license sanctions.

Vermont hospital nurse admitted diverting patient drugs; civil suit tested confidentiality of board investigative files

A patient sued a hospital, its administrator and a registered nurse, alleging the nurse injected herself with drugs meant for the patient and injected water from the tainted syringes into the patient to conceal it. The Secretary of State, as custodian of Board of Nursing records, produced a stipulation of settlement in which the nurse admitted diverting drugs for personal use while employed by the hospital, but sought to withhold the investigative file. The Vermont Supreme Court in its January 1990 term declined to block the trial court's order compelling production of the remaining records.

Mississippi nurse anesthetist's license revocation over unaccounted Demerol reversed by state supreme court

A 1981 hospital audit found that a substantial quantity of controlled narcotics signed out to a nurse anesthetist could not be accounted for as administered, in inventory, or wasted. The Mississippi Board of Nursing charged 17 counts, dismissed all but five, and found the nurse failed to reasonably account for Demerol, revoking the license. The Mississippi Supreme Court held in October 1984 that a failure to account was not a legally cognizable ground for revocation under the statute charged, reversed the chancery court, and directed that the license be restored.

DC agency nurse's Demerol pull for a patient with an expired order led to two-year suspension, upheld on appeal

A registered nurse working a night shift through a temporary help agency at a Washington, DC hospital in February 1980 signed out 50 mg of Demerol for a patient whose prescription had expired two weeks earlier. The patient never received the drug, and no other nurse witnessed the disposal of the surplus. The nurse testified the drug was wasted, but the Board found the nurse not credible, concluded the Demerol was unlawfully possessed on the pretext of administering it to a patient, and suspended the license for two years. The DC Court of Appeals affirmed the suspension in March 1983, after the nurse had been acquitted of related criminal charges.