There has been a lot of chatter on list serves within the diversion prevention community about the nearly 8 gallons of fentanyl diverted from a New Hampshire hospital. The initial report stated, “At least 23 bags of the drug had been removed without being wasted or provided to patients”, but that number climbed to 583. The hospital put a few prevention measures in place and yet, roughly 11 more bags went missing.
The reaction from some is “how could this even happen?”. Didn’t the hospital have the basic reconciliation processes in place? For others, it serves as a reminder that perhaps it could happen at their facility, and they find themselves wondering if they could have their own gaps they are completely unaware of. Some are wondering how peers did not notice any signs of diversion, or if did they notice but failed in their duty to report. The Chief Nursing Officer, who had her license suspended, is probably wondering all of the above. It sounds like their chain of custody gaps are large and many. It sounds like they did not do a full assessment of those gaps upon the initial discovery of diversion. If you have not had a comprehensive gap analysis, I highly suggest that you do. Rxpert Solutions has a great team that can do that for you. We’ll find out today (June 29th) if the pharmacy’s license will be suspended or revoked.
In February of 2022, Alexandra Towle, the RN who self-reported, admitted to diverting a majority of those 583 fentanyl bags for self-use. Like so many healthcare professionals with a substance abuse problem, Alexandra was a top student in high school and a competitive athlete. We know she went on to become an ICU nurse. On March 3, 2022, Ali passed away unexpectedly at the age of 30, leaving behind her son and family who loved her dearly. The cause of death has not been released, but I think we can come to an educated conclusion. My heart breaks for this family and young lady who reached out for help just weeks before passing away. Let this tragedy remind you of your obligation to make sure your facility is not making it easy for a healthcare professional to gain access to dangerous drugs for self-use. May she rest in peace.
Alexandra Olivia Towle
Jan 13, 1992 – March 3, 2022