The news out of Medford, Oregon, in December 2023 was explosive: A nurse in the intensive care unit of a local hospital had reportedly stolen patients鈥� intravenous fentanyl and replaced it with unsterile tap water for months. Dozens of patients developed infections. At least three died.
But it wasn鈥檛 the first time Asante Rogue Regional Medical Center had discovered an employee stealing narcotics.
A pharmacy technician stole drugs from the hospital from August 2016 through July 2017, according to . The board found Asante Rogue Regional hadn鈥檛 adequately secured the drugs or supervised the technician.
The board imposed a $20,000 penalty, but the hospital got to pay just $5,000 for complying with board-approved plans to fix the pharmacy鈥檚 issues over the next three years.
Six years later, the hospital faces over the most recent drug thefts. More suits are expected, as attorneys say they have been approached by dozens of former patients so far. The families of at least three patients who died have said the hospital notified them their loved one鈥檚 fentanyl was likely replaced.
The cases at Asante Rogue Regional illustrate the breakdowns of accountability at the heart of what experts call 鈥渄rug diversion鈥� 鈥� the theft of opioids and other controlled substances by health care workers from medical facilities. There is no good data on the scope of the problem, but researchers estimate that as many as 1 in 10 health care workers have stolen drugs.
The system of oversight and discipline has not kept pace with the crisis, experts say. The patchwork of state, federal and professional regulators to which hospitals are required to report drug diversion rarely share information among themselves. The Drug Enforcement Administration, which investigates 鈥渟ignificant鈥� drug losses and thefts, is under no obligation to share information with state agencies. State regulatory boards such as the Board of Nursing and Board of Pharmacy may share relevant information with federal agencies or one another but haven't always done so. As a result, none has tracked every incident of drug theft in Oregon.
Disciplinary actions are often limited, providing little leverage to enforce change. And hospitals frequently take prevention more seriously only after high-profile incidents that involve criminal charges, multimillion-dollar settlements or both, experts say.
鈥淭his is the occupational hazard of our industry that nobody talks about,鈥� said Rodrigo Garcia, a nurse-anesthetist, speaker and advocate who co-founded a substance use disorder treatment center for health care workers after diverting opioids himself more than a decade ago. 鈥淭here are a lot of incentives to keep this quiet.鈥�
Garcia and two other experts said the problems aren鈥檛 just tied to government standards and regulators, but that professional accrediting agencies also fail to motivate hospitals to be more proactive.
To learn more about drug diversion incidents in Oregon, InvestigateWest searched for public orders from the Board of Pharmacy against any of the 63 hospitals currently licensed by the Oregon Health Authority. The board oversees hospital and community pharmacies in Oregon, and also manages the licenses of pharmacists and pharmacy technicians.
InvestigateWest found that only six of those hospitals had faced discipline over confirmed or potential drug diversion in the last two decades. Each had to comply with quality assurance plans for at least a year, but the penalties they faced were sometimes less than the value of the drugs stolen.
That is far from a complete picture of how often drugs have been stolen from Oregon hospitals. For example, several facilities where the state Board of Nursing had disciplined a nurse for diverting drugs had no disciplinary history with the Board of Pharmacy.
This siloing of agencies is not unique to Oregon, according to experts.
鈥淭here鈥檚 no national database that collects this information that you can find,鈥� said Charlie Cichon, executive director of the National Association of Drug Diversion Investigators. 鈥淓very state is different as far as sanctions, and investigations are often never public. You may never find out about it.鈥�
Amid that data vacuum, drug theft from health care facilities is rarely addressed through public policy. Instead, advocacy groups have been pushing hospitals to take more preventative steps. Those steps can range from increasing drug security and audits of their own processes to offering tangible support for health care workers struggling with substance use disorders.
Accrediting agencies and federal and state regulators could take on more active roles in enforcing their own standards, experts said.
鈥淢aybe this is the kind of tragic case that is going to make somebody reach out to senators of Oregon and say, 鈥楬ey look, this is something that needs to be done,鈥� said Larry Houck, a former investigator with the DEA who now represents hospitals facing discipline over drug diversion. 鈥溾�業t鈥檚 a national problem 鈥� this happened in our state, and this is something that you should take on.鈥欌��
Scant data, scattered oversight
The Oregon Health Authority investigates health care facilities鈥� compliance with the standards of the Centers for Medicare and Medicaid Services, which include keeping controlled substances locked away and maintaining accurate records of where every dose goes.
But when asked about the 2017 drug theft at Asante Rogue Regional, a spokesperson confirmed that the agency had no record of the incident. Unlike the Board of Pharmacy, it likely never received a report.
Neither federal nor state law requires hospitals to report drug diversions or other possible violations of Medicare or Medicaid standards to the health authority, except if they result in certain kinds of infections, said Anna Davis, a manager with the agency. Her team receives most of its reports from patients, she said.
Davis鈥� team did receive a complaint about the latest drug theft allegations at Asante, said spokesperson Jonathan Modie, and the agency investigated 鈥渋n a timeframe that reflected both the seriousness of the allegations and our staff capacity to conduct an investigation of that size and complexity.鈥�
鈥淔rom the information we had received, we knew that the hospital had already taken steps to identify the problem and remediate the situation,鈥� Modie said.
But the Oregon Health Authority鈥檚 picture of how often drugs have been stolen from hospitals is incomplete. Licensing boards that oversee nurses, doctors and pharmacists are allowed to provide information related to 鈥渢he regulatory or enforcement functions鈥� of another public agency but are not obligated to do so, according to a Board of Pharmacy spokesperson.
This lack of data persists nationally. In recent years, the National Association of Drug Diversion Investigators and a handful of other organizations have banded together to try to track the problem across the country, forming a group called . Its database draws on news reports and press releases from the Drug Enforcement Administration. Members of the public can also make reports to the organization.
鈥淭he sooner a pattern of diversion is detected, the sooner organizations can intervene to mitigate future incidences of diversion,鈥� the website states.
The Board of Pharmacy鈥檚 disciplinary orders shed light on some drug theft in Oregon hospitals.
InvestigateWest found that five hospitals in addition to Asante had faced discipline over drugs that were stolen or simply unaccounted for in the last two decades. The facilities span the state, from Good Samaritan Hospital in Corvallis to Good Shepherd Medical Center in Hermiston.
In some cases, the hospital discovered drugs were stolen and reported it to the pharmacy board in accordance with state law. In others, the facility found evidence that a dose of a narcotic had been tampered with, and the board, after investigating, found security vulnerabilities that violated state laws.
In addition to any penalties they face, hospitals have to submit improvement plans to fix the issues the board identifies, submitting regular updates for a few years.
Penalties can vary widely depending on the severity and frequency of the violations. St. Charles Medical Center in Bend faced the most severe discipline, InvestigateWest found, including a three-year probation with the potential for its license to be revoked if any violations occurred during that period.
The executive director of the Board of Pharmacy declined to discuss the details of individual investigations, citing confidentiality rules. A spokesperson said that generally, the board weighs a variety of factors when deciding what discipline to impose, including 鈥渢he facts of the case, aggravating/mitigating factors, past licensee discipline, past board decision in similar circumstances (if any).鈥�
Meanwhile, other regulatory boards in Oregon, such as the Medical Board, which licenses physicians, and the Board of Nursing, only have oversight of individual licensees and not the facilities where they work.
The DEA, which enforces the Controlled Substances Act, requires hospitals to report theft or significant losses of controlled substances, which can sometimes trigger an investigation. But Garcia said he鈥檚 seen plenty of cases where hospitals simply fire the professional without making any report to the DEA.
Even when the agency receives a report, Houck said, it may not have the resources to investigate every one in detail. Investigations may come only after patients or health care workers have already been harmed.
To avoid the loss of their DEA registration in those cases, hospitals can wind up paying millions of dollars in civil penalties. They also enter into agreements to fix the deficiencies that led to injuries or deaths.
鈥淭he bottom line is patient health, but also some of the cases 鈥� showed that there have been a number of employees who overdosed and died, so it鈥檚 also your employees鈥� health. It鈥檚 your public image,鈥� Houck said. 鈥淭here鈥檚 just so much involved, that if you don鈥檛 do what you need to do, it鈥檚 pretty costly.鈥�
Discipline preceded disaster
To resolve the Board of Pharmacy鈥檚 discipline in 2017, Asante Rogue Regional added security cameras to the pharmacy area, improved staff training on security protocols, and tracked its compliance with the state鈥檚 rules on ordering, storing, and taking inventory of controlled substances.
It鈥檚 not clear what other prevention measures the hospital may have put in place outside of the pharmacy. Asante declined an interview request for this story.
Most details of the more recent drug thefts remain unconfirmed while investigations are ongoing. The Jackson County District Attorney鈥檚 Office is reviewing a months-long police investigation to determine whether to bring criminal charges against the nurse who allegedly swapped the fentanyl.
The malpractice lawsuit filed in February against Asante names Dani Marie Schofield as the nurse responsible for the fentanyl swap. Schofield has not been named in any criminal action and has denied responsibility in an interview with The Lund Report. Her lawyer did not respond to a request for comment.
Schofield agreed to voluntarily suspend her nursing license in November 2023 while investigations were under way, and it expired in April.
In the lawsuit and interviews with local media, several patients and their families have shared harrowing experiences from the Asante ICU, mostly involving complications from infections. The plaintiff in the lawsuit is the estate of Horace Wilson, a 65-year-old who died after developing sepsis while recovering from a surgery removing his spleen.
Based on patient testimonials and when Asante began notifying patients, the nurse may have been replacing the fentanyl for nearly two years or more.
Garcia, who advocates for a multifaceted approach to preventing drug thefts, said the length of time that diversion continues undetected is not just a matter of logistical practices failing to catch providers in the act. It can also speak to the culture of the health care facility, and whether employees struggling with a substance use disorder feel like they can admit their problem and find support before they鈥檙e in crisis.
In his treatment program, Garcia said, 鈥�95% enter into treatment because they were caught, they got fired or they get pushed into it and are mandated to receive treatment.鈥�
鈥淔ive percent of people will raise their hand and say, 鈥楾his is not looking good, I need help,鈥欌�� he said. 鈥淎 good program is where they ask for help.鈥�
Improvements require investments
Health care facilities are unlikely to be able to prevent all drug theft, but they can improve their abilities to stop it as soon as possible, Houck and Cichon said.
鈥淚f somebody鈥檚 diverting, and you have a granular record-keeping and an inventory accountability system in place, you're going to find that, and not have somebody do it for a long period,鈥� Houck said. 鈥淚鈥檝e always said there is no system that is not able to be compromised by someone. But it鈥檚 just a matter of how long they鈥檙e able to do it.鈥�
Houck pointed to settlements between the DEA and hospitals as reference points for how hospitals can improve. Those steps can range from mandatory random drug testing of employees to setting up security cameras at all places where drugs are dispensed. Other hospitals are required to do physical inventories 鈥渕ore frequently than required by law.鈥�
Much of the momentum for improvement is coming from groups like the National Association of Drug Diversion Investigators, and advocates such as Garcia.
In recent years, a handful of tech companies have stepped in to provide services to help reduce the burden on hospitals to improve record-keeping and systems that can flag discrepancies early.
Garcia, meanwhile, has his eye on independent hospital accrediting agencies such as the Joint Commission or Council on Accreditation. These organizations set their own standards for patient safety and care, which may be more stringent than the federal minimums. In addition to satisfying state regulations and carrying greater prestige, hospitals also reap the rewards of accreditation through the ability to bill insurance companies more for services.
If stricter preventive strategies against drug diversion could be tied to accreditation, Garcia said, 鈥淭hat鈥檚 a big motivator.鈥�
Agencies and policymakers could also increase the minimum standards hospitals need to follow or step up enforcement of existing standards.
The state Legislature sets state standards for health care, and it could tighten regulations, direct agencies to work collaboratively on the issue or create requirements to report violations related to drug security.
Rep. Kim Wallan, R-Medford, said she hadn鈥檛 seen the state as having a role to play to help prevent an incident like the latest one at Asante Rogue Regional. But she said she was shocked to learn that hospitals may not report every loss of controlled substances to the DEA, and that they aren鈥檛 required to let the Oregon Health Authority know.
鈥淚f hospitals know drugs go missing and don鈥檛 report it, that鈥檚 a huge concern,鈥� she said. 鈥淚鈥檒l poke around now that you鈥檝e asked.鈥�
At the federal level, Congress could instruct agencies that deal with drug security and care standards, including the DEA and the Centers for Medicare and Medicaid Services, to work collaboratively to support or enforce hospitals鈥� compliance with federal standards. Congress has created multi-agency task forces to study pain management, mental health and substance use disorders among veterans and trauma-informed care.
鈥淚 think so many agencies are silos and they kind of work their own areas of responsibility,鈥� Houck said. 鈥淢aybe it鈥檚 something that Congress needs to tell various agencies: 鈥楾his is what we need to focus on.鈥欌��
InvestigateWest () is an independent news nonprofit dedicated to investigative journalism in the Pacific Northwest. Reporter Kaylee Tornay covers labor, youth and health care issues; her most recent investigation explored of Oregon's only nursing facility for medically fragile children. Reach her at 503-877-4108 or kaylee@invw.org. On Twitter .