In December 2023, news broke that a nurse at Asante Rogue Regional Medical Center reportedly stole fentanyl from patients in the intensive care unit, by replacing their IV medication with tap water. This wasn’t the first time narcotics were stolen by an employee at the hospital, and it isn’t the only hospital in Oregon where this is happening. Poor data collection and oversight makes drug diversions hard to track among local, state and federal agencies. Kaylee Tornay is a reporter for InvestigateWest. She joins us with more.
The following transcript was created by a computer and edited by a volunteer:
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. News out of Asante Rogue Regional Medical Center in December made its way around the country. It was horrifying. A nurse at the Medford Hospital reportedly stole fentanyl from patients in the intensive care unit by replacing their IV medication with tap water. Dozens of patients reportedly developed infections, at least three people died. This was not the first time narcotics were stolen by an employee at the hospital and it isn’t the only hospital in Oregon where this is happening. But according to Kaylee Tornay, a reporter for InvestigateWest, poor oversight and data collection make drug diversions hard to track in Oregon and around the country. She joins us with more. Welcome back to the show.
Kaylee Tornay: Thanks, Dave.
Miller: So as you’ve reported, a lot of the details of this case in Medford remain unconfirmed pending investigations. But what can you tell us about what happened?
Tornay: So in December, family members of patients, or sometimes patients themselves, began receiving phone calls from the hospital, from Asante Rogue Regional, basically informing them that the hospital had been made aware that a nurse may have been engaging in this behavior and that they believed that they had been impacted by this. So people had, as you mentioned in your introduction, developed infections. A couple of those folks who received phone calls [and] who spoke with local reporters, shared about their family members who had even died as a result of complications from infections. We also learned that Medford Police had been informed about this potential drug diversion and were investigating to see if criminal charges were going to be filed.
Miller: What details have emerged from patients and their families in lawsuits or interviews with other media?
Tornay: Yeah, it definitely varies. People, of course, enter the hospital for all kinds of different reasons. But the threat of infections is definitely kind of a through line that a lot of these cases have in common, where people were prescribed fentanyl to be received through a central line and that’s where they had infections. And in some of these cases, even young healthy people died and so it’s quite tragic. There has been one lawsuit filed so far and from what we hear, there may be more to come.
Miller: I mentioned the reports of at least three deaths. But I’ve seen reports that some lawyers are talking about bringing suits on behalf of the families of dozens of people who died at the hospital. Can you help us to understand this huge discrepancy?
Tornay: Yeah. I’ve spoken with some of those lawyers and heard directly myself as well that they’re working with, like you said, dozens of people who received these phone calls or who maybe had similar experiences to what’s been already described in these public reports in the media. I think there’s some complicated stuff to navigate around. These lawyers are all working with medical experts who are combing through thousands of pages of documents and medical and health records to make a determination for the attorneys then to say, “yeah, this person may have a case.”
And then there’s also questions of statutes of limitations, because it is apparent that this may have affected patients for about almost two years, is sort of the timeline that’s spelled out right now, based on the lawsuit and when people were starting to be notified. But lawyers say that they have cases that go back even further than that and so not all of those potentially may be viable. So I think there’s just some legal complexities, I imagine, in addition to the health information these lawyers are all trying to navigate.
Miller: This is a horrific and really high profile case. But it’s not the first time that this particular hospital discovered that an employee was stealing narcotics. What happened there seven and eight years ago?
Tornay: So this other incident that happened was in 2016, 2017, according to this public order from the State Board of Pharmacy – which Asante, as a hospital that distributes prescription drugs, has to have a registration as a drug outlet with the State Board of Pharmacy in addition to federal registration with the drug enforcement administration. But this public order detailed an incident where it was discovered that a pharmacy tech was able to access and basically steal prescription drugs. The Board of Pharmacy, when they investigated, found the hospital had basically failed to follow Oregon rules that it’s required to follow to secure these drugs [and] to properly and adequately supervise this technician so that they wouldn’t be able to do this. And the hospital faced some discipline from the Board of Pharmacy as a result.
Miller: What were the repercussions for the hospital?
Tornay: So the order states that they had to submit these quality assurance plans for a number of years, kind of saying basically how they were fixing the issues that the board identified in its investigation. That included things like adding security cameras around where the narcotics vault was, auditing its processes and record keeping to make sure every dose can be accounted for. And they also had to pay a civil penalty of $20,000. But $15,000 of that was basically held back as long as the hospital was compliant and didn’t have any similar violations and there’s no evidence or no record showing that they had any other violations. So it’s like the hospital paid about only $5,000 of that total.
Miller: Looking here at the bigger picture, do researchers have a sense for just how common drug diversion or drug theft in hospitals is nationwide?
Tornay: As you also kind of mentioned in the introduction, the data on actual incidents is quite spotty. There’s sort of an effort to begin to try to record some of these incidents from a few groups, but officially, there really isn’t a data set that you can consult to see how often this is happening. So what researchers have done is use other data sources, like the National Survey of Drug Use and Health and a study by the National Institute of Justice, that surveyed healthcare workers on how often they have stolen medications. And a few experts that we talked to said that they trust the estimate of one in every 10 health care workers [are] diverting a substance at some point. So, it’s not insubstantial.
Miller: If true, it’s a staggering statistic. Your reporting may seem like this is one of those cases where there is such a patchwork of potential oversight, there ends up being very little oversight. I want to start at the highest level, at the federal level, with the Drug Enforcement Agency. What does the DEA do when it comes to this kind of theft?
Tornay: So hospitals and any sort of registrant with the DEA are required to report significant losses or thefts of controlled substances to the DEA. Experts will rightly point out that the term “significant” is not very specifically defined. So that definitely leaves room for facilities to kind of potentially not report every issue. The DEA, when it does receive reports, basically has its own investigatory process, where they look into things like the amount of harm, how this apparently happened, were standards not adhered to within the Controlled Substances Act?
Then, in these extreme situations where there are deaths or [in] extremely high profile situations, those investigations sometimes do get handed over to federal prosecutors. And hospitals sometimes settle for millions and millions of dollars and also agree, similarly like what they do with the State Board of Pharmacy agreements, to fix their issues basically and to come back into compliance with the law.
Miller: What about at the state level, at the Oregon Health Authority? You note that as the state’s Medicaid and Medicare administrator, OHA has to enforce federal standards, including things like making sure that healthcare facilities keep controlled substances locked away or maintaining accurate records of where every dose goes. Do they do that?
Tornay: When OHA gets a report of problems, they investigate. The thing is that hospitals are not required to report necessarily if they discover an issue and so there’s no obligation to or requirement to self report. When I spoke with a manager on the team that tends to investigate some of these types of issues, she told me that most of their reports come from patients. I know that they are aware of this particular incident that we’ve been talking about, that’s still under investigation by all these different bodies. They’re doing their own investigation and so they’ll make these recommendations to the Center for Medicare and Medicaid Services. And that’s the body that actually imposes any sort of discipline, but OHA has recommendations to make.
So, yes, they do investigate when they know about them. But it doesn’t take long looking at these cases that are documented by the Board of Pharmacy orders, for example, or maybe the Board of Nursing, to know that OHA does not know about all of these incidents, not by a long shot.
Miller: Well, what about the Oregon Board of Pharmacy? Are they on top of this?
Tornay: Again, in theory, there is the requirement to report unprofessional conduct to the Oregon Board of Pharmacy. I think the experts that I spoke with would tell you that not everything is going to be reported. It’s very common for
hospitals, when they discover something, depending on what exactly happened to let the healthcare worker go, discipline them, something like that and then just kind of wash their hands of the situation.
So the Board of Pharmacy, when it receives those reports, does investigate in a similar way to what we saw with the 2016, 2017 incident and any orders or discipline. Those investigations are confidential, it’s not easy to find out about them. But when they result in some sort of discipline, then that does become public. And those are the orders that we search for among the hospitals to get a sense of how many times, or how frequently hospitals have been disciplined for involvement in drug diversion.
Miller: How does Oregon’s system right now, which in a lot of ways seems like a lack of a system in practice, compare to the rest of the country?
Tornay: I think it is pretty common that there is sort of this siloing of agencies both at the federal level and then at individual state levels. I do think there are other states that have a bit more aggressive of an approach. I just spent a brief amount of time looking into Ohio, as an example, and I think that there is potentially a bit more of an open door of communication between the Board of Pharmacy and maybe law enforcement or other agencies. But we’re not unique in that we do not track drug diversion in all its variety and complexity very well here.
Miller: You talked to a nurse, an anesthetist named Rodrigo Garcia, who co-founded a substance use disorder treatment center for healthcare workers after, himself, diverting opioids more than a decade ago. What are he or other advocates pushing for right now in terms of policy changes?
Tornay: Rodrigo is a really great person to talk to about this to kind of understand some of the sides that maybe aren’t as talked about as much with regard to this issue. He really wants people to consider not just the “how” of how these incidents happen, but why they happen, why people divert, why are they in positions where they decide, even though they know what these drugs do, how powerful they are, to do this. So he has a pretty multifaceted approach to trying to change. I think that starts a lot with education and sort of resisting the stigma of the whole topic. Then also [resisting] the desire to kind of downplay or just not take a hard look at your own systems, but to get curious and to be educated on how frequently researchers believe that this happens.
He also is looking at accrediting agencies which have another role to play as well, in holding hospitals to certain standards for care and patient safety and all kinds of things like that. He’s also trying to open a conversation with some of these accrediting agencies, which are really important to hospitals for their reputations, for their ability to bill insurance in certain ways. And trying to get these accrediting agencies on board with taking perhaps a little bit more proactive stance or a more aggressive stance on the standards that hospitals need to meet. Not just for these logistical things of drug security and audits and those sorts of things, but also their culture of support and trying to tackle stigma that can also contribute to these behaviors going on and on without someone raising their hand and saying, “Hey, I need help.” Because to him, that is another metric of what an effective drug diversion prevention and response looks like.
Miller: Kaylee, just briefly – are any Oregon leaders taking up this charge?
Tornay: I’m spending a little bit of time this week reaching out to legislators and making sure that they see the story. I also spoke with Representative Kim Wallan. The hospital, I believe, is in her district. She represents Medford. And she was definitely pretty interested in the topic. So I don’t know of any policy fixes or changes that might be coming quite yet, but it sounds like it is something that definitely is catching some lawmakers eyes, at least.
Miller: Kaylee, thanks very much.
Tornay: Thank you.
Miller: Kaylee Tornay is an investigative reporter at InvestigateWest.
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