{"id":13679,"date":"2026-06-03T09:00:00","date_gmt":"2026-06-03T09:00:00","guid":{"rendered":"https:\/\/medical-article.com\/?p=13679"},"modified":"2026-06-03T09:00:00","modified_gmt":"2026-06-03T09:00:00","slug":"at-a-tennessee-hospital-a-nurse-stole-fentanyl-and-ai-missed-it-state-records-say","status":"publish","type":"post","link":"https:\/\/medical-article.com\/?p=13679","title":{"rendered":"At a Tennessee Hospital, a Nurse Stole Fentanyl and AI Missed It, State Records Say"},"content":{"rendered":"

About a year ago at Erlanger Baroness, the largest hospital in Chattanooga, anesthesia staff noticed that a nurse was slurring his words and struggling to stay awake while on duty in the surgery center, according to a Tennessee Board of Nursing consent order<\/a>.<\/p>\n

In the days that followed, the nurse failed a drug test and was fired, the order states. The nurse later admitted that for months he had pilfered and abused fentanyl left over after surgeries, sometimes daily, according to the order.<\/p>\n

Under most circumstances, this would be a routine case of what is known as \u201cdrug diversion,\u201d the unlawful taking of controlled substances from healthcare facilities \u2014 believed to be so widespread that it occurs at just about every U.S. hospital.<\/p>\n

But the Erlanger case stands out because a high-tech watchdog was supposed to be on guard.<\/p>\n

The hospital uses the newest line of defense against drug diversion: Sentri7, medication-monitoring software<\/a> powered by artificial intelligence and designed to detect missing drugs faster than any human can. But for months at Erlanger, Sentri7 failed to raise alarms, overlooking missing drugs and other \u201cinconsistencies\u201d that \u201cshould have been flagged,\u201d the nursing board\u2019s order states.<\/p>\n

The Erlanger case, which has not been previously reported, offers a rare glimpse at an apparent failure of AI drug diversion software used in hundreds of U.S. hospitals with little transparency or oversight. Healthcare facilities are not required to disclose their implementation of this kind of software or report malfunctions to anyone, so there is no full account of how widely these programs are used or how often they fail.<\/p>\n

Erlanger Baroness, also referred to as Erlanger Medical Center, declined to comment on its use of Sentri7 or on the diverted drugs. Andr\u00e9 Rebelo, a spokesperson for the health division at Wolters Kluwer, the Dutch technology company behind Sentri7, declined to answer questions about what happened at Erlanger but said the company remained \u201cconfident in our software.\u201d<\/p>\n

Little Transparency<\/strong><\/p>\n

David Rastall, a Johns Hopkins Medicine neurologist and AI researcher, said that because AI technology is heavily proprietary and hospital officials often don\u2019t understand how it works, this lack of transparency allows for errors to be buried rather than fixed. That means errors could be repeated at other hospitals, he said.<\/p>\n

\u201cThe ideal for patients, caregivers, and hospital systems would be,\u201d Rastall said, \u201cwhen an AI is found to be making some type of error, that becomes very transparent and public.\u201d<\/p>\n

The Drug Enforcement Administration mandates that hospitals confidentially report lost or stolen drugs. Hospitals can also report stolen drugs to state health agencies, which license medical professionals and investigate wrongdoing.<\/p>\n

But these reports are not required to include details about any AI software involved, according to interviews with three drug diversion prevention experts. In interviews, all said they had never seen an AI failure publicly documented like the apparent one at Erlanger.<\/p>\n

\u201cI\u2019ve never myself seen these technologies be called out in that specific way,\u201d Jacob Smith, a pharmacist in charge of drug security at Johns Hopkins Medicine, said of the apparent Sentri7 failure. \u201cIt doesn\u2019t make sense to me how you could miss it.\u201d<\/p>\n

Smith and other experts said the Erlanger case also raises questions because the theft of leftover drugs is one of the most well-known methods of diversion. And fentanyl, a painkiller that can be 50 times as strong as heroin, is one of the most common targets.<\/p>\n

Terri Vidals, the founder of Rxpert Solutions<\/a>, questioned whether the Erlanger case was the result of user error instead of malfunction.<\/p>\n

\u201cThis is the most basics of basics for this software,\u201d Vidals said. \u201cI find it interesting that they\u2019re saying it wasn\u2019t flagged by the software. I think there\u2019s maybe more to that story.\u201d<\/p>\n

The apparent Sentri7 failure at Erlanger was revealed by the Tennessee Department of Health in a routine release of state disciplinary orders<\/a> in December. Among those records was the Board of Nursing order, which summarizes a state investigation into nurse anesthetist John Stevenson, who settled the case against him by signing the document in November.<\/p>\n

Stevenson declined to comment through his attorney. He has not been charged with any crime related to the Erlanger case. The nursing board put his license on probation while he went to drug counseling.<\/p>\n

Bill Christian, a spokesperson for the Department of Health and Board of Nursing, declined to comment on the Erlanger case or Sentri7. In response to public records requests, the Department of Health and the Tennessee Health Facilities Commission each said it possessed no other documents about the apparent Sentri7 failure at Erlanger.<\/p>\n

Erlanger spokesperson Charlie Milburn said earlier this year that the hospital had prepared a written statement about its use of Sentri7 in response to questions from KFF Health News.<\/p>\n

That statement was never released.<\/p>\n

\u201cOur legal team is debating whether this is something we want to talk about at all,\u201d Milburn said in a March email, before later declining to answer any questions.<\/p>\n

Kristy Drollinger, a Wolters Kluwer executive who spoke generally about Sentri7 to KFF Health News in March, said the software is in high demand because so many hospitals have struggled to secure their drugs.<\/p>\n

Sentri7 monitors about 60 \u201cattributions of risk\u201d that identify red flags for further investigation by hospital employees, Drollinger said.<\/p>\n

\u201cIt\u2019s pretty scary,\u201d Drollinger said of widespread drug theft. \u201cEvery health system, every health facility, has had diversion at some point \u2014 and probably has it now.\u201d<\/p>\n

\u2018The Way of the Future\u2019<\/strong><\/p>\n

Drug diversion is a widespread challenge in U.S. medical facilities. It can lead to patients not receiving medication or getting drugs that are contaminated with blood-borne diseases. It\u2019s estimated as many as 15% of all healthcare workers divert drugs at least once, according to the nonprofit Healthcare Diversion Network<\/a>.<\/p>\n

Diversion has been linked to at least 13 disease outbreaks<\/a> \u2014 causing more than 200 infections, mostly of hepatitis C \u2014 since 1985, according to the Centers for Disease Control and Prevention.<\/p>\n

To prevent this, hospitals attempt to track each pill or vial from the moment it is dispensed to the moment it is given to a patient, by comparing data from electronic medication cabinets and patients\u2019 health records.<\/p>\n

Hospital staff once performed this painstaking process manually, but in the past decade the task has become largely automated by anti-diversion software. After years of mergers and buyouts, two programs now dominate the industry: Wolters Kluwer\u2019s Sentri7 and Bluesight\u2019s ControlCheck. Both incorporate AI.<\/p>\n

\u201cIt\u2019s definitely the way of the future,\u201d said Luke Overmire, owner of Diversion Specialists<\/a>.<\/p>\n

More than 1,500 hospitals use ControlCheck, according to Bluesight. An additional 700 use Sentri7 Clinical Surveillance programs, which can include its drug diversion software, according to Wolters Kluwer.<\/p>\n

Neither company publishes the price of its software. Smith, the drug safety official from Johns Hopkins, said hospitals purchase these \u201cexpensive technologies\u201d because a disastrous diversion case could result in a multimillion-dollar fine from the DEA.<\/p>\n

\u201cThey don\u2019t promise a return on investment,\u201d Smith said. \u201cThey promise cost avoidance.\u201d<\/p>\n

In 2022, a peer-reviewed study<\/a> funded by the National Institutes of Health found that Sentri7, then known as Flowlytics, could uncover drug diversion faster than existing methods. The study\u2019s primary author worked for Invistics, the company that previously owned Sentri7.<\/p>\n

According to that study, researchers tested the software by having it comb through medication data spanning two years and 10 hospitals in search of 22 nurses who were already known to have diverted drugs.<\/p>\n

The program not only found them all, the study states, but found them faster than humans by as little as a week and as much as a year and a half.<\/p>\n

At Erlanger, the humans spotted the signs of trouble first.<\/p>\n

According to the Board of Nursing order, co-workers reported that Stevenson appeared impaired \u201cwhile on duty in the surgery center\u201d on or around June 30, 2025.<\/p>\n

Stevenson \u201chad slurred speech, appeared extremely tired, was seen standing with his eyes closed and swaying, exhibited head nodding while standing upright and appeared to have difficulty keeping his eyes open,\u201d according to the order.<\/p>\n

When questioned by state investigators, Stevenson admitted that he began diverting \u201cunused fentanyl that would otherwise have been wasted after surgical procedures\u201d in March 2025, according to the order. Stevenson said he used the fentanyl waste once or twice a week at first, then \u201cincreasing to daily use\u201d by June of that year, the order states.<\/p>\n

Erlanger audited Stevenson\u2019s dispensing record over those four months. It found approximately five instances when Sentri7 didn\u2019t flag missing drugs, according to the order.<\/p>\n

It adds that the hospital found \u201cadditional inconsistencies between drug dispensing and waste documentation that should have been flagged by the automated monitoring system.\u201d<\/p>\n

One possible explanation is provided by the Board of Nursing, which said in the order that Sentri7 was in its \u201cinitial learning phase\u201d at Erlanger, though the board provided no details.<\/p>\n

In an interview, without discussing Erlanger specifically, Drollinger said Sentri7 has no \u201clearning phase,\u201d because it is trained on nine to 12 months of historical data when implemented at a new hospital.<\/p>\n

Smith, of Johns Hopkins, had another theory.<\/p>\n

In an interview, Smith said his experience with AI drug diversion software had led him to believe that it is effective at monitoring emergency rooms and intensive care units but less so in operating rooms, where drugs are dispensed and charted differently.<\/p>\n

These areas can be harder for AI to track, Smith said, and therefore require humans to keep a closer watch.<\/p>\n

\u201cWe\u2019ve got people whose entire job is to work with this software,\u201d Smith said. \u201cThe software is a piece of it, but if you rely on the software to give you all your signals, you\u2019ll miss stuff. It\u2019s just not 100%.\u201d<\/p>\n

KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/em><\/p>\n

This <a target=”_blank” href=”https:\/\/kffhealthnews.org\/health-industry\/ai-drug-diversion-theft-artificial-intelligence-hospitals-sentri7-software-tennessee\/”>article<\/a&gt<\/a>; first appeared on <a target=”_blank” href=”https:\/\/kffhealthnews.org”>KFF<\/a> Health News<\/a> and is republished here under a <a target=”_blank” href=”https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/”>Creative<\/a> Commons Attribution-NonCommercial-NoDerivatives 4.0 International License<\/a>.<img src=”https:\/\/kffhealthnews.org\/wp-content\/uploads\/sites\/8\/2023\/04\/kffhealthnews-icon.png?w=150&quot<\/a>; style=”width:1em;height:1em;margin-left:10px;”><\/p>\n

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About a year ago at Erlanger Baroness, the largest hospital in Chattanooga, anesthesia staff noticed that a nurse was slurring his words and struggling to stay awake while on duty in the surgery center, according to a Tennessee Board of Nursing consent order. In the days that followed, the nurse failed a drug test and…<\/p>\n","protected":false},"author":0,"featured_media":13680,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-13679","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/13679"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=13679"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/13679\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/media\/13680"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=13679"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=13679"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=13679"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}