A few yr in the past at Erlanger Baroness, the most important hospital in Chattanooga, anesthesia workers observed {that a} nurse was slurring his phrases and struggling to remain awake whereas on responsibility within the surgical procedure middle, in line with a Tennessee Board of Nursing consent order.
Within the days that adopted, the nurse failed a drug take a look at and was fired, the order states. The nurse later admitted that for months he had pilfered and abused fentanyl left over after surgical procedures, generally each day, in line with the order.
Below most circumstances, this is able to be a routine case of what’s often known as “drug diversion,” the illegal taking of managed substances from healthcare amenities — believed to be so widespread that it happens at nearly each U.S. hospital.
However the Erlanger case stands out as a result of a high-tech watchdog was alleged to be on guard.
The hospital makes use of the most recent line of protection in opposition to drug diversion: Sentri7, medication-monitoring software program powered by synthetic intelligence and designed to detect lacking medicine sooner than any human can. However for months at Erlanger, Sentri7 failed to lift alarms, overlooking lacking medicine and different “inconsistencies” that “should have been flagged,” the nursing board’s order states.
The Erlanger case, which has not been beforehand reported, gives a uncommon glimpse at an obvious failure of AI drug diversion software program utilized in a whole bunch of U.S. hospitals with little transparency or oversight. Healthcare amenities usually are not required to reveal their implementation of this sort of software program or report malfunctions to anybody, so there isn’t any full account of how extensively these packages are used or how usually they fail.
Erlanger Baroness, additionally known as Erlanger Medical Middle, declined to touch upon its use of Sentri7 or on the diverted medicine. André Rebelo, a spokesperson for the well being division at Wolters Kluwer, the Dutch know-how firm behind Sentri7, declined to reply questions on what occurred at Erlanger however stated the corporate remained “confident in our software.”
Little Transparency
David Rastall, a Johns Hopkins Drugs neurologist and AI researcher, stated that as a result of AI know-how is closely proprietary and hospital officers usually don’t perceive the way it works, this lack of transparency permits for errors to be buried slightly than fastened. Meaning errors could possibly be repeated at different hospitals, he stated.
“The ideal for patients, caregivers, and hospital systems would be,” Rastall stated, “when an AI is found to be making some type of error, that becomes very transparent and public.”
The Drug Enforcement Administration mandates that hospitals confidentially report misplaced or stolen medicine. Hospitals may also report stolen medicine to state well being businesses, which license medical professionals and examine wrongdoing.
However these studies usually are not required to incorporate particulars about any AI software program concerned, in line with interviews with three drug diversion prevention consultants. In interviews, all stated they’d by no means seen an AI failure publicly documented just like the obvious one at Erlanger.
“I’ve never myself seen these technologies be called out in that specific way,” Jacob Smith, a pharmacist in control of drug safety at Johns Hopkins Drugs, stated of the obvious Sentri7 failure. “It doesn’t make sense to me how you could miss it.”
Smith and different consultants stated the Erlanger case additionally raises questions as a result of the theft of leftover medicine is likely one of the most well-known strategies of diversion. And fentanyl, a painkiller that may be 50 instances as sturdy as heroin, is likely one of the most typical targets.
Terri Vidals, the founding father of Rxpert Options, questioned whether or not the Erlanger case was the results of person error as an alternative of malfunction.
“This is the most basics of basics for this software,” Vidals stated. “I find it interesting that they’re saying it wasn’t flagged by the software. I think there’s maybe more to that story.”
The obvious Sentri7 failure at Erlanger was revealed by the Tennessee Division of Well being in a routine launch of state disciplinary orders in December. Amongst these data was the Board of Nursing order, which summarizes a state investigation into nurse anesthetist John Stevenson, who settled the case in opposition to him by signing the doc in November.
Stevenson declined to remark by way of his lawyer. He has not been charged with any crime associated to the Erlanger case. The nursing board put his license on probation whereas he went to drug counseling.
Invoice Christian, a spokesperson for the Division of Well being and Board of Nursing, declined to touch upon the Erlanger case or Sentri7. In response to public data requests, the Division of Well being and the Tennessee Well being Amenities Fee every stated it possessed no different paperwork concerning the obvious Sentri7 failure at Erlanger.
Erlanger spokesperson Charlie Milburn stated earlier this yr that the hospital had ready a written assertion about its use of Sentri7 in response to questions from KFF Well being Information.
That assertion was by no means launched.
“Our legal team is debating whether this is something we want to talk about at all,” Milburn stated in a March e-mail, earlier than later declining to reply any questions.
Kristy Drollinger, a Wolters Kluwer govt who spoke usually about Sentri7 to KFF Well being Information in March, stated the software program is in excessive demand as a result of so many hospitals have struggled to safe their medicine.
Sentri7 displays about 60 “attributions of risk” that determine purple flags for additional investigation by hospital workers, Drollinger stated.
“It’s pretty scary,” Drollinger stated of widespread drug theft. “Every health system, every health facility, has had diversion at some point — and probably has it now.”
‘The Way of the Future’
Drug diversion is a widespread problem in U.S. medical amenities. It may possibly result in sufferers not receiving medicine or getting medicine which might be contaminated with blood-borne ailments. It’s estimated as many as 15% of all healthcare employees divert medicine a minimum of as soon as, in line with the nonprofit Healthcare Diversion Community.
Diversion has been linked to a minimum of 13 illness outbreaks — inflicting greater than 200 infections, principally of hepatitis C — since 1985, in line with the Facilities for Illness Management and Prevention.
To forestall this, hospitals try to trace every capsule or vial from the second it’s distributed to the second it’s given to a affected person, by evaluating information from digital medicine cupboards and sufferers’ well being data.
Hospital workers as soon as carried out this painstaking course of manually, however prior to now decade the duty has change into largely automated by anti-diversion software program. After years of mergers and buyouts, two packages now dominate the business: Wolters Kluwer’s Sentri7 and Bluesight’s ControlCheck. Each incorporate AI.
“It’s definitely the way of the future,” stated Luke Overmire, proprietor of Diversion Specialists.
Greater than 1,500 hospitals use ControlCheck, in line with Bluesight. An extra 700 use Sentri7 Medical Surveillance packages, which may embody its drug diversion software program, in line with Wolters Kluwer.
Neither firm publishes the worth of its software program. Smith, the drug security official from Johns Hopkins, stated hospitals buy these “expensive technologies” as a result of a disastrous diversion case might lead to a multimillion-dollar fantastic from the DEA.
“They don’t promise a return on investment,” Smith stated. “They promise cost avoidance.”
In 2022, a peer-reviewed examine funded by the Nationwide Institutes of Well being discovered that Sentri7, then often known as Flowlytics, might uncover drug diversion sooner than current strategies. The examine’s major creator labored for Invistics, the corporate that beforehand owned Sentri7.
In line with that examine, researchers examined the software program by having it comb by way of medicine information spanning two years and 10 hospitals looking for 22 nurses who have been already identified to have diverted medicine.
This system not solely discovered all of them, the examine states, however discovered them sooner than people by as little as per week and as a lot as a yr and a half.
At Erlanger, the people noticed the indicators of bother first.
In line with the Board of Nursing order, co-workers reported that Stevenson appeared impaired “while on duty in the surgery center” on or round June 30, 2025.
Stevenson “had 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,” in line with the order.
When questioned by state investigators, Stevenson admitted that he started diverting “unused fentanyl that would otherwise have been wasted after surgical procedures” in March 2025, in line with the order. Stevenson stated he used the fentanyl waste a couple of times per week at first, then “increasing to daily use” by June of that yr, the order states.
Erlanger audited Stevenson’s allotting report over these 4 months. It discovered roughly 5 situations when Sentri7 didn’t flag lacking medicine, in line with the order.
It provides that the hospital discovered “additional inconsistencies between drug dispensing and waste documentation that should have been flagged by the automated monitoring system.”
One attainable clarification is offered by the Board of Nursing, which stated within the order that Sentri7 was in its “initial learning phase” at Erlanger, although the board offered no particulars.
In an interview, with out discussing Erlanger particularly, Drollinger stated Sentri7 has no “learning phase,” as a result of it’s skilled on 9 to 12 months of historic information when carried out at a brand new hospital.
Smith, of Johns Hopkins, had one other principle.
In an interview, Smith stated his expertise with AI drug diversion software program had led him to consider that it’s efficient at monitoring emergency rooms and intensive care items however much less so in working rooms, the place medicine are distributed and charted in a different way.
These areas might be tougher for AI to trace, Smith stated, and subsequently require people to maintain a better watch.
“We’ve got people whose entire job is to work with this software,” Smith stated. “The software is a piece of it, but if you rely on the software to give you all your signals, you’ll miss stuff. It’s just not 100%.”
