AI Drug Monitoring Software Missed Months of Fentanyl Thefts at Tennessee Hospital

A nurse anesthetist at Erlanger Baroness hospital in Chattanooga diverted fentanyl from operating rooms for months in 2025 before the hospital's AI-based drug monitoring software raised any alerts. Anesthesia staff observed the nurse slurring words and struggling to stay awake on duty.

The nurse later failed a drug test, was terminated, and admitted to taking leftover fentanyl, sometimes daily, according to the Tennessee Board of Nursing consent order released in December. The hospital uses Sentri7, an AI-powered medication surveillance program sold by Wolters Kluwer and deployed at hundreds of U.S. hospitals.

The nursing board order states that Sentri7 overlooked missing drugs and other inconsistencies that should have been flagged.

Hospitals are not required to report AI software malfunctions or disclose their use of diversion-detection tools. The Tennessee Department of Health and the Tennessee Health Facilities Commission stated they hold no additional records on the Erlanger incident beyond the nursing board order.

Wolters Kluwer spokesperson André Rebelo declined to comment on the specific case but said the company remained confident in its software. Erlanger Baroness also declined to comment.

Drug diversion affects an estimated 15 percent of healthcare workers at least once and has been linked to at least 13 disease outbreaks since 1985, according to the Centers for Disease Control and Prevention. Two AI-based systems, Sentri7 and Bluesight's ControlCheck, now dominate the market.

Johns Hopkins Medicine pharmacist Jacob Smith said he had never seen an AI failure documented in this manner. Johns Hopkins neurologist David Rastall noted that proprietary AI systems limit external review of errors. Rxpert Solutions founder Terri Vidals questioned whether the failure reflected user error rather than a software malfunction.

The nurse, John Stevenson, settled the case with the nursing board; his license was placed on probation and he was referred to drug counseling. He has not been charged with a crime.