Officials continue to investigate a Boulder Community Hospital 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 may have received a saline solution rather than a powerful painkiller because a surgical nurse replaced the drug with the solution, Boulder officials said.
The surgical 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.
As a result, 200 letters have gone out to those patients advising them they may have been affected by the switch, 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 of Fentanyl.
The nurse was immediately terminated, said Sheehan. The nurse is not being named because charges have not been filed in the continuing police investigation.
The gravity of the situation was stressed this afternoon by Chris Lines, spokesman for the Colorado Department of Regulatory Agencies.
He said the Board of Nursing, one of the department’s agencies, also has launched “an ongoing investigation.”
He said if the allegations about the nurse prove to be true, he could lose his license and the right to practice in Colorado. The length of the license termination would be left to the board, said Lines.
Fentanyl is one of the most powerful opiod analgesics, with a potency 81 times that of morphine.
Another 120 patients who underwent surgery at the hospital, located at 1100 Balsam St., during the period from Sept. 24 to Oct. 17 have been notified as a courtesy, said Sheehan. But he said the surgical nurse under suspicion was not involved in their operations and that the hospital doesn’t believe they were affected.
Sarah Huntley, spokeswoman for the Boulder Police Department, said the hospital reported that 50 vials kept in what are called pyxis machines were tampered with by the nurse.
She said the hospital was able to track down who tampered with the vials because everyone entering the drug-storage units has an individualized access code and entry into the storage units is recorded.
The vials were not removed from the units, but the painkiller was removed and the saline solution substituted for the drug, said Huntley.
Huntley and Sheehan said suspicions were raised when 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, said Sheehan.
“There were concerns in anesthesiology that made us aware of this,” said Sheehan. “We talked to the nurse. He admitted to tampering, and that is why he was terminated.”
Both Huntley and Sheehan said the 200 patients would not have experienced discomfort while the operation was in progress.
“The anesthesiologist is constantly monitoring the patient and can give more painkiller if the patient is showing signs of discomfort,” said Sheehan. “The height and weight of the patient is taken into consideration. Each person responds differently, and adjustments are made accordingly.”
In the letter to the patients, Dr. Owen Ellis, the chair of the hospital’s anesthesia department, said there is “an extremely small risk” that patients who received the saline solution might develop a blood stream infection.
“The symptoms of this type of infection are a high fever and shaking chills,” said Ellis. If such symptoms develop within two weeks of surgery, said Ellis, the patient should immediately contact their primary care physician or go to the nearest emergency service for evaluation.
“We deeply regret this incident and apologize for any inconvenience,” he added.
Sheehan said that units of Fentanyl are kept at various locations around the hospital, but the only location affected was the unit where Fentanyl was stored for surgery.
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. Any unusual patterns will be investigated immediately.
“This incident is a violation of the patient’s trust, and we are truly sorry it occurred,” he said.
Huntley said the surgical nurse suspected of the tampering has been interviewed at length by Boulder police and that he is cooperating fully.
As of now, the case is being investigated as a felony theft. But charges related to any potential impact on the patients also may be considered, said Huntley.
Police are trying to determine exactly how the tampering took place and which vials were tampered with, she added.
Huntley said that it will probably be next week before the department wraps up its investigation.
The hospital reported the incident to Boulder police on Oct. 24 and to the Colorado Department of Public Health and Environment on Oct. 29.
Mark Salley, department of health spokesman, said the report submitted by the hospital is confidential. He said the hospital had a duty to report the episode to the health department and did so properly.
In addition to the Colorado Board of Nursing, the department of health also is reviewing the incident, said Salley.
Howard Pankratz: 303-954-1939 or Pankratz@denverpost.com
