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Nurse tampers with fentanyl vials

Healthcare Security Weekly, March 17, 2008

A Minnesota hospital has already made some changes to its security procedures after a nurse was caught tampering with its stock of the pain medication fentanyl.

Immanuel St. Joseph's Mayo Health System in Mankato suspended the nurse and has notified 335 patients they may have received saline solution instead of the intended drug, the Associated Press (AP) reported. The health system's president and CEO said there is no indication so far that any patients suffered ill effects from the nurse's actions.

The hospital began an investigation after workers found empty fentanyl vials in a wastebasket February 25, which were not disposed of in the usual way. The hospital said the nurse would open new vials of the drug, withdraw the contents, and replace it with sterile saline solution, the AP reported. The nurse would then self-administer the drug later, said the hospital, which has referred the case to authorities for possible charges.

The hospital issued letters to patients who had procedures involving sedation in the cardiac catheterization lab, endoscopy, and radiology departments during February and early March, who could have received affected medication.

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