Nurse Anesthetist Diverted Fentanyl at Chattanooga Hospital Despite AI Monitoring Software

Anesthesia staff at Erlanger Baroness hospital in Chattanooga noticed a nurse anesthetist slurring his words and struggling to stay awake while on duty in the surgery center on or around June 30, 2025. The nurse, John Stevenson, failed a drug test days later and was fired.

He later admitted he had been diverting and abusing leftover fentanyl after surgeries, sometimes daily, according to a Tennessee Board of Nursing consent order.

Stevenson began diverting unused fentanyl waste in March 2025 and increased his use to daily by June 2025. Erlanger audited his dispensing record over those four months and found approximately five instances when Sentri7 did not flag missing drugs. The hospital also identified additional inconsistencies between drug dispensing and waste documentation that should have been flagged by the software.

Stevenson signed the order in November 2025. The board placed his license on probation while he attended drug counseling. He has not been charged with any crime related to the case.

Erlanger Baroness uses Sentri7 medication-monitoring software powered by artificial intelligence. The Board of Nursing order stated that Sentri7 was in its initial learning phase at Erlanger. The hospital declined to comment on its use of the software or on the diverted drugs.

André Rebelo, a spokesperson for Wolters Kluwer, the company behind Sentri7, said the company remained confident in its software. David Rastall, a Johns Hopkins Medicine neurologist and AI researcher, said AI technology is heavily proprietary and hospital officials often do not understand how it works. He added that the ideal would be for AI errors to become very transparent and public.

Jacob Smith, a pharmacist in charge of drug security at Johns Hopkins Medicine, said he had never seen an AI failure publicly documented like the apparent one at Erlanger. He said it does not make sense to him how Sentri7 could miss the theft of leftover fentanyl. Terri Vidals, founder of Rxpert Solutions, questioned whether the case was the result of user error instead of a software malfunction.

She said detection of leftover fentanyl waste is the most basics of basics for this software. The Drug Enforcement Administration mandates that hospitals confidentially report lost or stolen drugs. These reports are not required to include details about any AI software involved.

It is estimated that as many as 15% of all healthcare workers divert drugs at least once, according to the Healthcare Diversion Network. Drug diversion has been linked to at least 13 disease outbreaks causing more than 200 infections, mostly hepatitis C, since 1985, according to the Centers for Disease Control and Prevention. More than 1,500 hospitals use Bluesight's ControlCheck.

An additional 700 hospitals use Wolters Kluwer's Sentri7 Clinical Surveillance programs, which can include its drug diversion software. A 2022 peer-reviewed study funded by the National Institutes of Health found that Sentri7 could uncover drug diversion faster than existing methods.