Yale Nurse Replaces Fentanyl Vials with Saline

[J.Adderton]

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?

[subee, MSN, CRNA]

16 hours ago, JKL33 said:

Not if you're not an addict but get funneled into one because of "diversion"--the definition of which has been seriously perverted in the past 5++ years or so.

I'm not trying to be paranoid here but I've been in one particular staff meeting where fingers were wagged all around the room and everyone was warned that if there is any discrepancy with any controlled substance we will be terminated and reported to our BON. This was in a large, "respectable" health system hospital with coveted, flashy designations.

I don't go for that, not when I'm running my *** off all shift and so is everyone else, there's difficulty with wasting meds in real time because of short staffing, etc. I just don't need this, I refuse to be treated this way or to treat others this way. It's a darn good thing I'm a decently cultured human being or I would have told this crazy blankety-blank who was wagging her finger around the room to eff right off.

Secondly, I am not aware of any widespread ignorance about addiction, or nurses and addiction. I'm not on a rampage here, I just seriously have not noticed ignorance of this being an issue. I've responded at least a few times in recent years to posts here about "signs of addiction" which have always bothered me because somehow at least 50% of the signs found on lists like these are utterly non-specific. I have a problem with that.

I am just not going to suspect people unless they give me a darn good reason to, and that's not because of ignorance it's because of my personal beliefs. If I have a serious concern about the well-being of a coworker, I don't even need to concern myself with the underlying "why." I am prepared (and willing) to speak with them and/or let someone know of my concern. If I have a serious concern about their care of patients I am prepared and willing to immediately get help.

Those are the only two things I need to be responsible for, and I am prepared to follow through.

 

This morning I was awakened by a nightmare that I had been working on roller skates all night when one of them broke down and I had all these patially used vials of controlled drugs in my pocket so that I could waste them all at once with a witness.  But I was so angry at a meaningless system that requires monitored wastes in vials that I could have just filled with water after using the left over drugs in them.  Our whole approach is wrong, wrong, wrong and causes PTSD! ?  If we learned to just watch people's behavior and don't try to diagnose what the problems is and just send them to the ER for evaluation, we have actually addressed the solution which is to get a correct diagnosis and let the nurse do what they have to do to address it.  El Al Airlines doesn't much time screening customers with technology.  They actually have trained screeners to ask questions with a trained ear.  And I disagree that we are knowledgeable about addictions.  We are quite the opposite.  Education is freaking slow but it is a lot better than it was in the 80's when diversion bills were passed while nurses were led out of the hospital by law enforcement.  There is nothing easy about doing it better and most people haven't the slightest idea how to do a work place intervention.

[LibraNurse27, BSN, RN]

Yes, the wasting is stressful. If you're busy and forget to waste and no one wants to sign with you because  you can't show them the drugs, you're screwed. What happens is people just sign for each other without verifying because we trust each other or are just too busy to wait around for someone to draw up and waste stuff, so the wasting does nothing but waste time and get people who aren't diverting in trouble. Just my opinion. 

Also, it makes me feel like a suspected criminal... maybe that's dramatic LOL

[PollywogNP, ADN, BSN, MSN, LPN, NP]

In the early 80s, I worked with a new grad RN that had been withdrawing Demerol from the Tubex pre-filled syringes. They cam 5 per pack, she would pierce the bottom of the pack & refill with saline. I was the only one that spoke up about strange behavior such as sitting in report in nurses station with sunglasses on , that I returned from dinner & she had medicated a couple of my patients with Demerol ( they had been on oral narcotics for past few days as it was policy to not have injection in days before discharge), be very tired & sleepy at start of shift report & after dinner running around  like the energizer bunny. She never used the break room bathroom instead a visitor bathroom. She was caught be supervisor injecting herself in a patient bathroom, it was end of shift, she was emptying Foley’s and went in  bathroom and closed the door, which supervisor thought was weird. Afterward night shift nurses then said that many patients had reported that the last shot given by this nurses did not take pain away, it was same RN & same LPN & though they had suspected they never said anything, sadly they were disciplined. No one in my shift said anything either. I was the only one that went to the manager & she had told the supervisor that I said something strange was going on with this nurse. I thought she was doing street drugs, never suspected stealing Demerol. Later the Tubex syringe packs had a piece of metal at the bottom.

[JKL33]

8 hours ago, subee said:

This morning I was awakened by a nightmare that I had been working on roller skates all night when one of them broke down and I had all these patially used vials of controlled drugs in my pocket so that I could waste them all at once with a witness.  But I was so angry at a meaningless system that requires monitored wastes in vials that I could have just filled with water after using the left over drugs in them.  Our whole approach is wrong, wrong, wrong and causes PTSD! ? 

I think that is why I have whatever resistance I have to this issue. I basically think healthcare corporations are corrupt with probably few exceptions. Whether they are corrupt or not their relationships with nurses are shot and their "leaders" are not fit to wield a broom let alone any kind of power and authority over nurses. They certainly cannot be trusted to handle any of this in an ethical manner. That's why I get a little wacko when I see these list of nothingness that could indicate a problem with addiction (e.g. "offers to work overtime"). It's why I become furious when subjected to a lecture where some self-important jerk (who IS a nurse) threatens a whole room of professionals who don't even know why we're there getting lectured. [Oh, and just for fun, we were also told during that same rant that it wasn't just opiates but any medication that is not properly documented as having been administered or wasted amounts to "diversion" and also theft of hospital property.]

 

8 hours ago, subee said:

And I disagree that we are knowledgeable about addictions.  We are quite the opposite. 

What I mean is that I think most nurses know the gist of things; if something is completely screwy with a coworker then yeah, sure...they could be having a problem with a substance abuse disorder--or any number of other personal or work-related problems. As someone who works with other people who are taking care of patients, I really do think that it's about as simple as "either I have serious concern or I don't." If I have a serious concern then I would be concerned about the coworker's well-being and the safety of their patients. If I am concerned then I will get help for those two reasons; I don't need to know what their problem is.

One thing for sure, teaching nurses about non-specific things that "might" indicate SUD is not a complete education. Deciding to have something high on one's list of suspicions every time someone doesn't act xyz way is not appropriate and is a dangerous mindset in and of itself when other things may very well be even more likely/common than SUD. Hospitals use stuff like this to their advantage; they don't care about any nurse. That's why they have co-opted the issue of "diversion" to mean anything they want it to. For example.

I will agree about lack of education on the basis that, as you indicated, there are systems-level things and also philosophies/attitudes that could go a long way toward decreasing problems overall. Non-specific lists, threatening lectures, and treating people like criminals when they have done nothing wrong is not the answer.

[JKL33]

40 minutes ago, PollywogNP said:

In the early 80s, I worked with a new grad RN that had been withdrawing Demerol from the Tubex pre-filled syringes.

I can appreciate your story and experience. If I had witnessed all of that then I would have also expressed concern.

But...part of the problem is that it usually isn't easy for one person to witness and track all abnormalities and put them together. For example, if an ED patient tells me that their pain shot did nothing...well, that's just another day in the life of an ED nurse, you know? ? I'm not voicing any concerns about a coworker over something like that. Not using the staff breakroom bathroom? Well, maybe it's just too odd to have people sitting at a table 15 feet away eating their lunch. I will say the sunglasses would have had me saying, "take those glasses off..." ? but other than very tell-tale things it's just not simple. It looks like it should have been simple after the fact, but actually when I'm at work I'm often way too busy to pay close attention to what other RNs are doing, so I might notice something odd here or there but not a whole long list of odd things from one person.

Everyone has heard of a situation like this. But everybody hearing about it still wouldn't make it a super-common, top-of-the-list suspicion.

[subee, MSN, CRNA]

It's not as simple as identifying one odd behavior.  It's a constellation of behaviors.  Our job is not to diagnose the behavior as an addiction or anything else because we are not trained in diagnosing.  Our job is simply to note that there are concerns.  No one really notices anything until the person is so far gone they are making gross mistakes and getting sloppy.  And of course, in anesthesia, where people work alone most of the time, over-doses have become a part of a long career.   I've received calls from OR's with CRNA's unarousable  during a case with hep locks in.  CRNA's driving with hep locks in while using propofol.  CRNA's dead in motel rooms, bathrooms, sniffing gasses until unconscious.  You get the drift.  It pays for everyone to have their antennae up.  I also worked with a nurse who was sent to the ER for slurred speech who was known to be a drinker.  She was OD'ing on her Inderal (?) and died a few days later. It's not always narcotics but other factors that contribute to jpb shrinkage.  By the time a busy staff notices anything, something is usually very wrong.

 

[pal]

I think that nurses have to be accountable for their actions, she had an addiction and put others at risk. Yes nurses probably have a harder time getting help due to a number of things but I think the biggest one would be the shame that comes along with it.... its not so much the getting help that's the problem but what would people think. Humility is something we don't practice on a daily basis, if we did whenever we see we had a problem we would get help. I have sympathy for this woman and if I put myself in her shoes of addiction I'm not sure what lengths I would have gone to feed that monster. I am glad she is getting help and can hopefully still have a good life.  I wish nothing but the best for her recovery .

[PollywogNP, ADN, BSN, MSN, LPN, NP]

5 hours ago, subee said:

It's not as simple as identifying one odd behavior.  It's a constellation of behaviors.  Our job is not to diagnose the behavior as an addiction or anything else because we are not trained in diagnosing.  Our job is simply to note that there are concerns.  No one really notices anything until the person is so far gone they are making gross mistakes and getting sloppy.  And of course, in anesthesia, where people work alone most of the time, over-doses have become a part of a long career.   I've received calls from OR's with CRNA's unarousable  during a case with hep locks in.  CRNA's driving with hep locks in while using propofol.  CRNA's dead in motel rooms, bathrooms, sniffing gasses until unconscious.  You get the drift.  It pays for everyone to have their antennae up.  I also worked with a nurse who was sent to the ER for slurred speech who was known to be a drinker.  She was OD'ing on her Inderal (?) and died a few days later. It's not always narcotics but other factors that contribute to jpb shrinkage.  By the time a busy staff notices anything, something is usually very wrong.

 

Yes, there were lots of odd behaviors, I only listed a few but thinking back there were other clues that something in this nurse’s life was not right. Ran into her years later, she completed diversion and had returned to nursing. Did a paper for my BSN completion & learned that anesthesiologists & pharmacist had high addictions rates.  Another time a nurse reported for duty , he was drunk. The charge nurse was just going to send him home. Had to call supervisor since charge nurse was clueless about the possible ramifications. And the in the break room as clinical instructor overheard a new RN state out loud that she had a headache & did we think it would be OK if she took a Tylenol #3. The other nurse in the room started choking on his lunch! Don’t think she understood she would be “under influence of a narcotic” so even after thorough explanation, I told her to go talk to unit manager. Things like theses 2 examples that get nurses in trouble. 

[subee, MSN, CRNA]

17 hours ago, PollywogNP said:

Yes, there were lots of odd behaviors, I only listed a few but thinking back there were other clues that something in this nurse’s life was not right. Ran into her years later, she completed diversion and had returned to nursing. Did a paper for my BSN completion & learned that anesthesiologists & pharmacist had high addictions rates.  Another time a nurse reported for duty , he was drunk. The charge nurse was just going to send him home. Had to call supervisor since charge nurse was clueless about the possible ramifications. And the in the break room as clinical instructor overheard a new RN state out loud that she had a headache & did we think it would be OK if she took a Tylenol #3. The other nurse in the room started choking on his lunch! Don’t think she understood she would be “under influence of a narcotic” so even after thorough explanation, I told her to go talk to unit manager. Things like theses 2 examples that get nurses in trouble. 

One of the most frustating things was the number of hospitals who refused to allow an addictions RN into the facility to do a continuing ED on the unit after a nurse had been removed.  Those nurses needed to hear that talk NOW while their emotions and curiosity were high but hospital administrators generally want to keep it all hush-hush.  A few hospital systems have created remarkable programs for their OR's which address ALL members of the OR teams, including, for instance, even housekeeping to be on the alert for sloppy practices.  Anesthesiologists were the worst offenders for leaving Fentanyl syringes drawn up on the top of the anesthesia carts for the taking.  Since the CRNA's were previously nurses, they understand that they would be treated more harshly for doing the same thing and did what we had to do not to leave drugs accessible to everyone.  I remember a tragedy in the 90's where a small group of OR nurses were stealing left over Fentanyl from syringes left on the cart to take home for a little Fentanyl party.  Unknown to them was that the anesthesiologist had already removed the Fentanyl from the syringes and put Pavulon, an old timey muscle relaxant, in the syringes.  The nurses died together and when the OR found out what had happened the anesthesiologist killed himself the next day.  That's part of the reason I have no respect for the procedure of wasting drugs in front of anyone because that person has no idea what you are tossing - it's just a clear liquid like most other IV drugs we give throughout the hospital.  

[PoppieLady]

This is heartbreaking. 

[SmilingBluEyes]

On 3/22/2021 at 6:52 AM, subee said:

One of the most frustating things was the number of hospitals who refused to allow an addictions RN into the facility to do a continuing ED on the unit after a nurse had been removed.  Those nurses needed to hear that talk NOW while their emotions and curiosity were high but hospital administrators generally want to keep it all hush-hush.  A few hospital systems have created remarkable programs for their OR's which address ALL members of the OR teams, including, for instance, even housekeeping to be on the alert for sloppy practices.  Anesthesiologists were the worst offenders for leaving Fentanyl syringes drawn up on the top of the anesthesia carts for the taking.  Since the CRNA's were previously nurses, they understand that they would be treated more harshly for doing the same thing and did what we had to do not to leave drugs accessible to everyone.  I remember a tragedy in the 90's where a small group of OR nurses were stealing left over Fentanyl from syringes left on the cart to take home for a little Fentanyl party.  Unknown to them was that the anesthesiologist had already removed the Fentanyl from the syringes and put Pavulon, an old timey muscle relaxant, in the syringes.  The nurses died together and when the OR found out what had happened the anesthesiologist killed himself the next day.  That's part of the reason I have no respect for the procedure of wasting drugs in front of anyone because that person has no idea what you are tossing - it's just a clear liquid like most other IV drugs we give throughout the hospital.  

Now THAT is horrible. I am so sorry for all involved, I really am.

[J.Adderton, BSN, MSN]

On 3/17/2021 at 5:57 PM, PsychNurse24 said:

I also have compassion for people with addictions. It is horrible to have such a desperation to use that you would steal and cause harm to others.  That’s why I hope she gets treatment and support.

I see it as a disease and positive she lived in unimaginable shame daily.