New Hampshire Hospital Lost Nearly 8 Gallons of Fentanyl

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Leaders at a Keene, New Hampshire hospital have been sanctioned after nearly 8 gallons of fentanyl went missing over a 5-month period.

Cheshire Medical Center’s chief nursing officer Amy Matthews, DNP, RN, had her nursing license suspended late last month, and hospital pharmacy director Melissa Siciliano, PharmD, had her license reinstated after a temporary suspension in connection to 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 Alexandra Towle, RN, had been diverting bags of fentanyl solution since October 2021.

At that time, it was reported that at least 23 bags of the drug had been removed “without being wasted or provided to patients,” according to the nursing board’s suspension order.

But during the hospital’s subsequent investigation, it was revealed that much more fentanyl had gone missing. By early March, the hospital reported that 283 bags were lost because of Towle’s actions — but it couldn’t account for 163 missing bags.

Those bags probably weren’t diverted, the hospital stated in a letter referenced in the board order. Instead, it was likely that “the challenges of the hospital work setting brought about by the COVID-19 winter surge ‘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 remedial measures in February and March, according to the board order. These measures included locking the second-floor medication room; reducing the number of fentanyl bags stored in the Omnicell; training nurse and pharmacy staff on preventing and detecting diversion; assigning pharmacy techs to Omnicell reports; and reinstituting an intensive care unit dual sign-off at the point of nursing documentation.

Nonetheless, by mid-May, it was discovered that an additional 554 mL of fentanyl, or about 11 bags, were lost or unaccounted for in the month prior.

The hospital’s chief pharmacist wrote in a letter that those bags probably weren’t diverted either, and that “corrective action measures including nursing education around documentation requirements for controlled substance administration and wasting are underway to improve the quality of documentation.”

The Drug Enforcement Administration is also investigating the case, according to local news reports.

A spokesperson for Cheshire Medical Center sent a statement that the hospital “continues to work closely with government agencies on the ongoing investigation of this matter, even as we revise and refine our policies and protocols regarding the secure handling of pharmaceuticals. Patient and employee safety are always our first priority, and we have a zero-tolerance policy regarding the diversion of any controlled substance.”