Yale Nurse Replaces Fentanyl Vials with Saline

A Yale infertility clinic failed to protect patients from pain when a nurse tampered with 75% of fentanyl vials intended for procedures over a 5 month period.  Read on to learn more about this story and how the pandemic adds to the risk of substance abuse among healthcare workers.

Yale Nurse Replaces Fentanyl Vials with Saline

On March 2nd, a former Yale nurse pleaded guilty to altering fentanyl vials intended for outpatient surgical patients.  The nurse, Donna Monticone, worked at the Yale Reproductive Endocrinology and Infertility clinic in Orange, Connecticut and was responsible for ordering and stocking narcotics needed for procedures.  According to the U.S. attorney’s office, the nurse began stealing fentanyl in June 2020 for her own personal use.  Monticone would remove the drug from secured vials, inject herself, then replace the fentanyl with saline.

No Protection from Pain

When Monticone pled guilty, she confessed to actions that are in direct conflict to nursing ethics and standards.  Specifically, she admitted to the following:

  • Knowing that the fentanyl vials she replaced with saline would be used in surgical procedures as an anesthetic.
  • Knowing patients could experience serious bodily harm without an anesthetic.
  • Injected herself with fentanyl while working at the clinic.
  • Eventually taking vials of fentanyl home for self injection.
  • Refilling the empty vials at home with saline and returning them to the clinic’s fentanyl stock.
  • Bringing around 175 vials of fentanyl vials she had taken from the clinic and discarded them in the clinic’s trash.

Investigators discovered that between June and October 2020, approximately 75% of the fentanyl administered to clinic patients for surgical procedures was either diluted or consisted only of saline.  

“I Screamed”

Patients detail the extreme pain they experienced during procedures at the Yale fertility center.  One patient recalls suddenly realizing the anesthesia she’d been given during a painful egg harvesting procedure was not working.  She shared her story with a local news station, stating, “It made me scream.  I remember screaming in the middle of the procedure from pain”. 

Attorney Josh Koskoff represents four victims who had IVF procedures while in extreme pain.  He describes the women as feeling betrayed and dismissed when clinic staff did nothing when they reported the pain.  Koskoff also questions how the complaints continued to go on for several months without a thorough investigation by the clinic.

Yale’s Response

Yale’s director of university media relations released a statement about the what is being done to reassure the public and prevent this from happening again.  Here is a look at what steps are being taken:

  • The clinic informed law enforcement of the theft and notified patients about the issue.
  • Informed patients there is no reason to believe the nurse’s actions harmed their health or treatment outcome.
  • A combination of pain medication is used during clinic procedures and are adjusted if signs of discomfort.
  • Making needed changes in procedures, record-keeping and storage to prevent diversion in the future.

Bond and Sentencing

Monticone was released on a $50,000 bond and will return for sentencing on May 25th, facing a maximum prison sentence of 10 years.  

Healthcare Workers at Increased Risk

Nurses stealing opioids for their own personal use is nothing new and there’s no shortage of news articles reporting criminal charges for diversion.  Now, the pandemic is intensifying the risk of substance abuse among healthcare workers.  During COVID-19, it’s not unusual for nurses to feel like their best is not good enough and the emotional, mental and physical toll can be overwhelming.  Navigating life during a pandemic is stressful already, but add to the mix the extra challenges healthcare workers have faced over the last year.  For example:

  • Long shifts and work hours
  • Fear of being infected by the virus
  • Fear of passing the virus on to vulnerable patients
  • Fear of passing the virus on to loved ones
  • Busy/chaotic work environments and unable to take time to talk to peers about stress and anxiety
  • Loss of outlets for stress due to social distancing
  • Financial hardships due to lay-offs and cancelled shifts during early pandemic

The pandemic has only added “fuel to the fire” in healthcare workers who are already at risk for substance use disorders.

What Do You Think?

Donna Monticone surrendered her nursing license and went to rehab.  I do believe she should face the consequences of her actions.  But, I also think the stigma and shame of being a nurse with an addiction prevents too many from seeking help.  What do you think… is there a bigger picture than what the news reports?

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J.Adderton

About J.Adderton, BSN, MSN

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J.Adderton has 28 years’ experience as a BSN, MSN and specializes in Clinical Leadership, Staff Development, Education.

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Specializes in Geriatrics.

This situation is tragic for everyone involved. First let me be clear that this is an egregious act on behalf of the nurse who is entrusted with caring for clients and safeguarding health care resources. I will say, however, that nurses are constantly put under pressure. (Not an excuse for stealing narcotics). I do believe that this pressure, from the job requirements to fears (of being sued, fired, getting sick, danger on the job) can cause a nurse to snap. You know, always being perfect can get to someone. A nurse can’t be tired, sick, sad, vulnerable, uneasy, unsure, scared, or anxious. A nurse is, by society’s definition, a character that is serene, calm, always knows what to do, does it, doesn’t complain, and doesn’t show any emotion other than sheer empathy. Nurses are human, we have our faults, but unfortunately can’t show it. Every day more and more is required, causing anxiety to raise to unbearable levels. So many nurses then turn to alcohol, drugs, or in extreme cases, narcotics. Who is to blame? We are taught that addiction is an illness. So where is the empathy for the person suffering from addiction? if this nurse was stealing insulin because she was a diabetic would we be in the same position? Again, this is wrong, we know patients were harmed. The real perspective is looking outside of the case and seeing the societal and ethical issues as a whole. We all know things need to change, how will we get there ? 

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Specializes in Addictions, Psych.

She caused undue harm to women already undergoing stressful and traumatic procedures. 

I feel empathetic for her situation but my anger on behalf of those women definitely outweighs it. 

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Specializes in Addictions, Psych.
10 minutes ago, vintagegal said:

if this nurse was stealing insulin because she was a diabetic would we be in the same position? 

Depends on the situation in which she was taking the insulin. Are we talking about skimming from the vial during a mealtime bolus? Or do we have a critical patient on an insulin drip, where she's refilled the bag with NS? 

The issue is she replaced the vials with saline. She wasn't skimming or pocketing waste. She allowed patients that had medical procedures requiring anesthesia to be given saline in lieu of fentanyl. That's unconscionable. 

People do all kinds of crappy things in the name of addiction. Addiction is a disease. But that does not give them a free pass for their actions. 

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Specializes in Critical Care.

I don't understand how over a period of at least 5 months, no staff using the fentanyl vials noticed that the caps were no longer sealed.

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Specializes in OR, Nursing Professional Development.
41 minutes ago, MunoRN said:

I don't understand how over a period of at least 5 months, no staff using the fentanyl vials noticed that the caps were no longer sealed.

If the procedures were being done under moderate sedation, and the nurse in the article was using them only on patients she was providing moderate sedation for, I can see how she would have been able to hide the opened seals.

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Specializes in OR, Nursing Professional Development.
10 hours ago, J.Adderton said:

I do believe she should face the consequences of her actions. 

Absolutely, both professional and criminal

But, I also think the stigma and shame of being a nurse with an addiction prevents too many from seeking help. 

I think many don't really get how big of a problem for them it is. It usually takes something like disciplinary action, OD, or being caught diverting that serves as a wake up call

What do you think… is there a bigger picture than what the news reports?

Can the news ever really report the full story? Many are seeking subscribers, so they sensationalize what they can, leaving less room for true detail.

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I know the quality isn't consistent, but it seems much simpler to just score on the street than to mess with stuff at work

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Specializes in New Critical care NP, Critical care, Med-surg, LTC.
On 3/15/2021 at 12:04 PM, Tacocat said:

She allowed patients that had medical procedures requiring anesthesia to be given saline in lieu of fentanyl. That's unconscionable. 

I agree that this is the bigger issue. If she had been stealing vials, or taking doses from vials, that would have been one thing. She probably would have been caught sooner, but it wouldn't have harmed patients in the process. 

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Specializes in Psychiatric, in school for PMHNP..

There are probably bigger pictures surrounding most criminals, but that doesn’t excuse the crimes.  Hopefully, this nurse will receive lifelong treatment and/or support, because addiction is a recurring, chronic condition.  But I think she needs to suffer the consequences of her actions.

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Specializes in Community health.

This is just tragic all around. Yes obviously she should lose her license etc but I also feel for anyone who is so desperate and addicted that she resorted to this. 

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Specializes in CRNA, Finally retired.
On 3/15/2021 at 6:28 PM, MunoRN said:

I don't understand how over a period of at least 5 months, no staff using the fentanyl vials noticed that the caps were no longer sealed.

People can re-glue the red seal.  I heard a CRNA speak about drilling small holes in the medication cylinders of IV pumps to capture narcotics; the doctor that substituted  scotch for his windshield wiper fluid and diverted the drainline to the side of the driver's door so he could suck it from the fluid line while driving.  I've seen a picture of a  dead doctor's office in Fla. of blood all over the walls while making an oops trying to insert his own central line and another Fla. doctor dead right there leaning over his feet to inject between the toes.  Health professional addicts are extraordinarily cunning.  The nurse in the OP's posted situation will not be eligible for a diversion program since it was a frank situation of patient harm.

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