Yale Nurse Swapped Fentanyl With Saline

Patients undergoing operations at a Yale fertility clinic believed they were receiving fentanyl when in fact a nurse had swapped it with saline.

That revelation emerged during a hearing Tuesday in New Haven’s U.S. District Court.

At the hearing, a nurse named Donna Monticone pleaded guilty to tampering with a consumer product as part of a deal with federal prosecutors. She faces up to 10 years in prison at a scheduled May 25 sentencing.

Monticone, 49, admitted that she stole fentanyl for her own use and substituted saline in the vials while working at Yale School of Medicine’s Reproductive Endocrinology & Infertility Institute between June and November 2020. She has surrendered her nursing license and no longer works for Yale.

Assistant U.S. Attorney Raymond Miller described Monticone’s crime during the hearing before U.S. District Court Judge Janet Hall.

He said that Monticone’s job was to order and inventory fentanyl at the clinic. The fentanyl, made by Pfizer (and shipped across state lines, thus making this a federal case), was one of three drugs used to relieve patients’ pain during outpatient surgeries.

“She started using fentanyl for her own use,” Miller said. ​“She would take a syringe, remove some or all of the fentanyl, inject it, and replace the solution with saline.

“She would then take those vials that had been diluted wholly or partially with saline and replace them in a secure location where Yale is required to keep fentanyl. She knew she was placing adulterated fentanyl in the proper storage location, where it would be used for surgical procedures.”

Because the solutions are clear, the switch was not apparent to the naked eye.

Monticone then began taking the vials of fentanyl home, injecting the drug there, Miller said. At one point, in late October or early November, aware that there might be problems, ​“she brought back 175 vials and attempted to put them” back.

“Approximately 75 percent of the fentanyl given to patients at the Yale REI clinic from June to October 2020 was adulterated with saline,” the U.S. Attorney’s Office said in a statement released after the plea hearing. ​“Some of the vials contained diluted fentanyl, while others contained no drug at all and contained just saline.”

Judge Hall asked Monticone if Miller’s allegations are accurate. She said yes.

“Did you know that fentanyl was being used for patients undergoing painful operations, meant to lower pain?” Hall asked.

“I was aware of that,” Monticone replied.

She then signed documents acknowledging her guilt. Deeming her not to be a flight risk, Hall agreed that she be released pending sentencing on a $50,000 surety bond. Monticone said she has been undergoing drug abuse treatment.

Monitcone, who lives in Oxford, was represented by a public defender, Allison Near.

Yale did not have an immediate comment following the hearing.

Attorney Josh Koskoff, who attended the hearing, represents some of the women who were patients at the clinic.

“The families want to understand how this was allowed to happen. This is a preeminent hospital that is supposed to be responsible for the oversight of medication so we hope Yale will provide the answers these women deserve about not just how it happened but what Yale is going to do to make sure it doesn’t happen to other women,” Koskoff said after the hearing.

Yale has told patients that ​“there is no reason to believe that the nurse’s action harmed their health or the outcome of their treatment. The Fertility Center routinely uses a combination of pain medications during procedures and modifies the medications if there are signs of discomfort,” Yale spokeswoman Karen Peart said in a release after the hearing.

“The University reported the nurse’s actions to law enforcement agencies, and the Fertility Center conducted an immediate review of its management of controlled substances. Changes are underway in procedures, recordkeeping, and physical storage that will prevent this type of activity from happening again.”