Officials continue to investigate a Boulder Community Hospital surgical nurse who replaced the painkiller Fentanyl with saline solution, and the hospital has taken steps to prevent a repeat of the situation.
As many as 200 patients operated on in September and October might have received a saline solution rather than the painkiller, Boulder officials said.
Fentanyl is one of the most powerful opioid analgesics, with a potency 81 times that of morphine.
The nurse, who began work at the hospital in June, was directly involved in the 200 operations during the period from Sept. 24 to Oct. 17.
Letters have gone out to those patients advising them they might have been affected, said Rich Sheehan, spokesman for the hospital.
Sheehan said the surgical nurse was confronted by hospital administrators Oct. 24 and admitted to tampering with the vials. The nurse was immediately terminated, Sheehan said. The nurse has not been identified because charges have not been filed.
The Board of Nursing, part of the Colorado Department of Regulatory Agencies, is also investigating, said spokesman Chris Lines.
Sarah Huntley, spokeswoman for the Boulder Police Department, said the hospital reported that 50 vials were tampered with by the nurse.
She said the hospital was able to track down the perpetrator because everyone entering the drug storage units has an individualized access code and entry is recorded.
Huntley and Sheehan said at least one anesthesiologist noticed that patients being operated on were not responding properly to what was supposed to be pain medication.
The anesthesiologist contacted the hospital’s chief of anesthesiology, director of surgery and pharmacy chief, Sheehan said.
Both Huntley and Sheehan said the 200 patients would not have experienced discomfort while the operation was in progress.
In the letter to the patients, Dr. Owen Ellis, chairman of the hospital’s anesthesia department, said there is “an extremely small risk” that patients who received the saline solution may develop a blood-stream infection.
Sheehan said the hospital has taken action to prevent a repeat of the situation. The hospital’s pharmacy has upgraded the system for monitoring drug usage to flag any suspicious patterns, he said.
The case is being investigated as a felony theft. Charges related to any potential impact on the patients also may be considered, Huntley said.
Howard Pankratz: 303-954-1939 or hpankratz@denverpost.com
