Cropped hand of doctor injecting patient

It sounds like a plot from a movie, but it’s heartbreakingly real: a hospital nurse swaps tap water for fentanyl when administering medication to patients in intensive care. Not only do the patients not receive the pain relief they need, but the non-sterile water causes serious infections, leading to multiple deaths.

This very scenario played out recently at Asante Rogue Regional Medical Center (RRMC) in Medford, Oregon, where an estimated 8-10 ICU patients died after being injected with tap water instead of fentanyl. The ICU patients were especially vulnerable to the pseudomonas infections that resulted; already medically frail, they succumbed to their infections.

Why would anyone, especially someone supposedly dedicated to patient care, do such a thing? The answer is drug diversion. And perhaps the only thing more heartbreaking than this occurrence is the fact that the RRMC drug diversion is only one of many drug diversion cases.

What is Drug Diversion?

Drug diversion happens when prescription drugs are obtained or used in an illegal or unauthorized way and diverted from their intended use. Drug diversion can take many forms, including:

  • Healthcare workers such as doctors, nurses, and pharmacy staff stealing prescription medication either to sell on the black market or for their personal use. This is likely what happened in the RRMC drug diversion case.
  • Drug swapping, or switching one type of medication for another, so that the swapped-out medication can be used or sold by the person diverting it.
  • Overprescribing of medication, especially opioids and other pain medication, which contributes to the risk that the person for whom the medication is prescribed will abuse or sell the drugs.

Fentanyl, the opioid at the center of the RRMC case, is one of the most commonly diverted drugs, along with other opioids such as oxycodone and hydrocodone. These drugs are highly addictive; people who originally took the medication for legitimate reasons may become addicted and continue to seek out the drugs through illegal channels.

While drug diversion often involves opioid medication, other drugs are commonly diverted as well, including benzodiazepines like Valium, Xanax, and Klonopin; stimulants like Adderall; anti-anxiety medicines like Ativan; muscle relaxants like Soma and Flexeril; and anesthesia drugs such as Propofol. Whatever the type of drug diverted, drug diversion, or failure of a facility to prevent it, may constitute medical malpractice.

How Common is Drug Diversion?

It is very difficult to know how common drug diversion is in hospitals and other healthcare settings. Because diversion is by nature a secretive activity, unless there is an outbreak of infection such as the one at RRMC, it often goes undetected. Even when drug diversion is detected, it frequently goes unreported due other health care workers closing ranks, or a facility’s desire to avoid negative publicity. Unfortunately, this secrecy allows drug diversion to continue, potentially harming a patient.

Although exact numbers for drug diversion in the United States are hard to come by, it is reasonable to infer that the increase in opioid addictions in recent years has led to a corresponding increase in drug diversion. What is known is that about 8-10% of healthcare workers abuse controlled substances—about the same percentage as in the general population. With millions of medication movement transactions taking place annually in healthcare settings, there are many opportunities for drug diversion to take place.

In even the best case scenarios, patients are deprived of medication they need (and for which they are billed). In the worst cases, like the Asante RRMC drug diversion matter, many patients may suffer and die needlessly.

Drug Diversion and Medical Malpractice

Most medical malpractice is the result of a medical error—a mistake that could and should have been prevented, but that was unintentional. Those cases are hard enough for the patients and families. When a vulnerable patient dies because of an intentional act like drug diversion or a facility’s failure to report or take action to prevent it, it is even harder on loved ones left behind. It can be difficult to stop thinking about how needless the loss was.

If you or a family member has been a victim of drug diversion, our hearts go out to you. As medical malpractice attorneys, we know that these situations are incredibly painful. If drug diversion resulted in the death of someone you love, there is simply no way to make things right, because you can’t get your loved one back.

It may provide some measure of closure to take legal action against the parties responsible for your loss: a provider who diverted drugs, and the healthcare facility and professionals who failed to prevent the drug diversion. Filing a medical malpractice claim can hold the responsible parties accountable for their action or inaction, and send a message to other providers that drug diversion must not be tolerated.

To learn more about drug diversion in Oregon, or to discuss a claim you may have for medical malpractice, contact The Fraser Law Firm P.C. to schedule a consultation.