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Hospital managers ignored AI alerts tracking nurse drug theft, federal investigation finds

A federal investigation of a California hospital revealed that automated systems detected a nurse stealing fentanyl and morphine, but staff failed to act on the warnings.

The short version

  • A Centers for Medicare and Medicaid Services investigation revealed that managers at Adventist Health in Bakersfield, California, ignored automated alerts warning of potential drug theft.
  • A travel nurse diverted fentanyl and morphine intended for patients for her own personal use, leaving at least one patient in excruciating pain.
  • The incident underscores the limitations of artificial intelligence and machine learning software in healthcare settings when human oversight is lacking.

Key facts

  • In late September 2024, a travel nurse at Adventist Health in Bakersfield, California, diverted fentanyl and morphine for personal use while documenting that they had been administered to patients.[STAT]
  • Patients and family members reported that the nurse was acting strangely, including walking barefoot through the intensive care unit and neglecting patient pain management.[STAT]
  • A Centers for Medicare and Medicaid Services investigation in November 2024 found that hospital managers ignored alerts from machine learning software designed to track potential drug theft.[STAT]

Sources