Leaders at a Keene, New Hampshire hospital were disciplined after nearly 8 gallons of fentanyl went missing over a 5-month period.
Cheshire Medical Center’s director of nursing, Amy Matthews, DNP, RN, had her nursing license suspended late last month, and the hospital’s director of pharmacy, Melissa Siciliano, PharmD, had her license reinstated after a temporary suspension in connection with the missing opioid, according to reports.
The problem started when a nurse was found to be diverting fentanyl. In February, Matthews filed a complaint alleging that Alexandra Towle, RN, had been diverting bags of fentanyl solution since October 2021.
At the time, at least 23 bags of the drug were reported to have been recalled “without being wasted or given to patients,” according to the board of nursing suspension order.
But during the hospital’s subsequent investigation, it was revealed that much more fentanyl had been lost. In early March, the hospital reported that 283 bags were lost due to Towle’s actions, but was unable to account for 163 lost bags.
Those bags likely were not diverted, the hospital stated in a letter referenced in the board’s order. Instead, it was likely that “hospital work environment challenges brought on by the winter surge of COVID-19 ‘impacted the ability of nursing staff to consistently document fentanyl infusion and administration.'”
Ultimately, the investigation revealed a total of 583 bags of fentanyl, nearly 8 gallons of the powerful opioid, went missing between September 2021 and January 2022.
In response, Cheshire Medical Center implemented corrective measures in February and March, per the board’s order. These measures included locking the medicine room on the second floor; reduce the number of fentanyl bags stored in the Omnicell; train nursing and pharmacy staff in the prevention and detection of deviations; assign pharmacy technicians to Omnicell reports; and reinstitute an intensive care unit double sign-off at the nursing documentation point.
However, in mid-May, it was discovered that an additional 554 ml of fentanyl, or about 11 bags, were lost or missing in the previous month.
The hospital’s chief pharmacist wrote in a letter that those bags likely weren’t diverted either and that “corrective action steps, including nursing education on documentation requirements for the administration and waste of controlled substances, are being taken to improve safety.” documentation quality.
The Drug Enforcement Administration is also investigating the case, according to local news reports.
A Cheshire Medical Center spokesperson released a statement saying the hospital “continues to work closely with government agencies on the ongoing investigation of this matter, even as we review and refine our policies and protocols regarding the safe handling of pharmaceuticals. The safety of patients and employees is paramount.” always our first priority, and we have a zero-tolerance policy regarding the diversion of any controlled substance.”