Nurse Replaced Pain Medicine With Saline

Female patients of a Yale fertility clinic underwent treatments in the hopes of starting a family. Something wasn’t right, and many women experienced terrible pain despite being given strong pain meds. A nurse had replaced pain medicine with saline. This kind of drug diversion could have been avoided, but patients suffered extreme pain due to the clinic’s negligence.

In this article, we share what happened. We take a look at the system that enabled a heavy drug user unrestricted access to fentanyl. How did this affect so many women? Why wasn’t anything done? Could this happen again?

Yale Fertility Clinic Nurse

Starting as early as 2019 and ending in late 2020, a Yale fertility clinic nurse named Donna Monticone began stealing fentanyl vials from her workplace at the clinic. The clinic had two locations where Donna worked, New Haven and Orange Connecticut. In her role, she was allowed unsupervised and unrestricted access to all the drugs used in the clinic. She began stealing fentanyl as early as 2019, but it lasted for several months before it was discovered. Donna was stealing the fentanyl vials and replacing the fluid inside with saline solution. This meant patients who were supposed to receive fentanyl received salt water instead.

How Did Yale Handle This Situation?

Patients complained of extreme pain with egg retrieval procedures. Doctors and nurses ignored the large increase in pain complaints. The women were ignored or dismissed as hysterical. Staff did not investigate until an anesthesiologist found a loose cap on several fentanyl vials.

The Yale fertility clinic cooperated with authorities. The investigation found Donna had acted alone, but the clinic had been negligent in preventing this situation. 

The clinic sent letters out to all patients, but the wording was confusing. In the letter, the clinic admitted a staff member was diverting drugs but stated the clinic believed no one was affected by the nurse’s actions. Due to the wording, many of the women affected by this had no idea their excruciatingly painful experience was linked to the drug diversion. Was the clinic trying to avoid a medical malpractice lawsuit?

How Did This Harm Patients?

Egg retrievals are an uncomfortable procedure. Additionally, each retrieval is part of a long process of injections, appointments, tests, and preparation. Patients going through egg retrievals in the clinic were supposed to receive fentanyl to stop the pain. Even with fentanyl, the procedure is very uncomfortable. Without the fentanyl a patient feels everything – and remember, this is a surgical procedure on an extremely sensitive area of the body.

In this situation, patients received only saline (salt water). For these patients, they felt everything in this painful procedure. Patients experienced ongoing, crippling pain that left some of them bedridden for days and weeks.

Despite complaining of extreme pain, the patients were told their pain was normal and/or they were overreacting. Yet, nursing staff at the clinic did notice more patients were experiencing extreme pain. Even so, the clinic did nothing to investigate.

Increase In Patients With Extreme Pain

How were so many patients experiencing this high level of pain when the average is closer to 1 or 2 patients per year? Why didn’t the clinic investigate how so many vials of fentanyl seemed ineffective at helping patients? In fact, it was only after an anesthesiologist noticed several loose caps that an investigation was launched.

It is unknown exactly how many patients were harmed by the actions of this nurse. At least 75 former patients believe they were affected, but there may have been more. Many patients were tricked into believing their pain was normal.

Fertility treatments are painful, embarrassing, expensive, and an emotional rollercoaster. Because of the pain and betrayal in this situation, some of the women gave up on their dream to have a child.

Support Group Offers Answers

Several of the women who were patients at the clinic connected through an online support group. Many of them thought their pain was normal. It was through talking with other patients they learned their pain was not normal. They also discovered many patients with higher levels of pain were all treated at the same clinic. The patients all received the same confusing letter. Some of them decided to talk to an attorney.

Medical Negligence

The lawsuit against the Yale fertility clinic is important for patients everywhere. This wasn’t the first time a healthcare worker diverted controlled substances from a Yale healthcare facility. Yale had the experience and knowledge of how drug diversion happens but did not enforce its own policies to prevent it.

Furthermore, the facility had an increased number of reports of extreme pain from patients but did not investigate. At the least, this clinic should have investigated why the fentanyl wasn’t working to manage pain.

When the clinic discovered its error and what the nurse had done, it downplayed the problem. The lawsuit on behalf of the women who suffered this experience provides several remedies.

Validation – The patients in this clinic experienced extreme pain, which was downplayed by doctors and nurses. A lawsuit will force the Yale healthcare system to admit there was a problem. This lawsuit helps provide validation for the horrible pain the patients suffered.

Prevention – This was a traumatic experience that could have been prevented with basic safeguards and enforcement. The lawsuit will act as a warning for healthcare facilities to prevent drug diversion.

Compensation – If successful, this lawsuit will provide money as compensation for the pain the patients endured. No amount of money will erase the horrible pain these women endured, but it also serves as punishment for the clinic’s negligence.

Could This Happen Again?

Drug diversion is a serious problem. Healthcare facilities must have procedures in place to prevent anything like this from happening again. Could this happen again? It could. The nurse in this situation received very little punishment. In fact, according to The Retrievals podcast, the nurse voluntarily quit and has a chance to keep her nursing license. This same nurse might have access to drugs at another healthcare facility. Other nurses at other facilities may have unsupervised access to pain medications.

When To Contact An Attorney

The patients in the story above were confused and didn’t understand their pain was caused by the clinic’s negligence. If you receive a letter from your healthcare provider about a possible breach of care, talk to an attorney. An experienced medical malpractice attorney can help investigate the situation and provide advice on the best way to proceed.

Kane & Silverman Medical Negligence Law Firm

At Kane & Silverman, we provide free consultations for any type of injury claim. Contact us today for a free consultation with a medical negligence attorney.

Medical malpractice laws are different in each state. Kane & Silverman attorneys are licensed to practice in Pennsylvania, New Jersey, and Maryland. If you need help finding an attorney in another state, we may be able to help. Contact us today!