2026-06-01T05:00:04-0400 / 哥伦比亚广播公司新闻
据田纳西州护理委员会的同意令显示，大约一年前，在查塔努加规模最大的医院埃尔兰格男爵夫人医院（Erlanger Baroness），麻醉科工作人员注意到一名护士在手术中心值班时言语含糊不清，且难以保持清醒。
该命令称，在随后的几天里，这名护士的药物检测呈阳性并被解雇。根据命令内容，这名护士后来承认，数月来他一直在盗窃并滥用手术后剩余的芬太尼，有时甚至每日都如此。
在大多数情况下，这会是一起典型的“药物转移”案件——即从医疗机构非法获取受管制物质，这类案件被认为极为普遍，几乎每家美国医院都有发生。
但埃尔兰格医院的这起案件却格外引人关注，因为本应有一个高科技监管系统负责警戒。
该医院采用了对抗药物转移的最新防御手段：Sentri7，一款由人工智能驱动的药物监测软件，旨在比人类更快地发现药物丢失情况。但据护理委员会的命令显示，在埃尔兰格医院的数月时间里，Sentri7未能发出警报，忽略了本应被标记的药物缺失和其他“不一致”情况。
这起此前从未被报道过的埃尔兰格医院案件，罕见地揭示了美国数百家医院使用的人工智能药物转移监测软件明显存在故障，且此类问题几乎没有透明度或监管。医疗机构无需披露其使用此类软件的情况，也不必向任何人报告软件故障，因此目前尚无全面数据说明这些程序的应用范围有多广，或是它们的故障频率有多高。
埃尔兰格男爵夫人医院，也被称为埃尔兰格医疗中心，拒绝就其使用Sentri7软件或药物转移事件置评。Sentri7的开发商、荷兰科技公司威科集团（Wolters Kluwer）卫生部门发言人安德烈·雷贝洛拒绝回答有关埃尔兰格医院事件的问题，但表示该公司仍“对我们的软件充满信心”。
透明度极低
约翰·霍普金斯大学医学院神经学家兼人工智能研究员戴维·拉斯托尔表示，由于人工智能技术具有极强的专有性，且医院管理人员往往并不了解其工作原理，这种透明度的缺失使得错误被掩盖而非得到修正。他说，这意味着其他医院可能会重复犯同样的错误。
“对于患者、护理人员和医院系统而言，理想的情况是，”拉斯托尔说道，“当人工智能被发现存在某种类型的错误时，这一信息能够高度透明并公之于众。”
美国药品 Enforcement 管理局（DEA）要求医院机密报告药物丢失或被盗的情况。医院也可以向州卫生机构报告被盗药物，这些机构负责发放医疗专业人员执照并调查不当行为。
但三位药物转移预防专家在采访中表示，这些报告并不被要求包含涉及任何人工智能软件的细节。他们在采访中均表示，从未见过像埃尔兰格医院这次明显的人工智能故障这样被公开记录的案例。
“我本人从未见过这些技术以这种特定方式被指出问题，”约翰·霍普金斯大学医学院负责药物安全的药剂师雅各布·史密斯在谈及Sentri7明显的故障时说道，“我无法理解怎么会漏掉这种情况。”
史密斯和其他专家表示，埃尔兰格医院的案件也引发了疑问，因为盗窃剩余药物是最常见的药物转移手段之一。而芬太尼这种镇痛剂的效力是海洛因的50倍，是最常见的目标药物之一。
Rxpert Solutions创始人特里·维达尔质疑，埃尔兰格医院的案件是否是人为操作失误而非软件故障导致的。
“这对这款软件来说是最基础的操作，”维达尔说道，“我觉得很奇怪，他们说软件没有标记出异常。我认为这件事背后可能还有更多隐情。”
田纳西州卫生部在12月例行发布的州纪律处分命令中披露了埃尔兰格医院Sentri7明显的故障。其中一份文件是护理委员会的命令，总结了对护士麻醉师约翰·史蒂文森的州调查情况，史蒂文森于11月签署该文件以了结针对他的案件。
史蒂文森通过其律师拒绝置评。他未因埃尔兰格医院的案件面临任何刑事指控。护理委员会在他接受药物治疗期间对其执照处以缓刑。
田纳西州卫生部和护理委员会发言人比尔·克里斯琴拒绝就埃尔兰格医院的案件或Sentri7软件置评。在回应公共记录请求时，田纳西州卫生部和田纳西州卫生设施委员会均表示，没有掌握任何其他有关埃尔兰格医院Sentri7明显故障的文件。
埃尔兰格医院发言人查理·米尔本今年早些时候表示，该医院已准备了一份关于其使用Sentri7软件的书面声明，以回应KFF健康新闻的提问。
但该声明从未发布。
“我们的法律团队正在讨论我们到底要不要谈论这件事，”米尔本在3月的一封电子邮件中说道，随后便拒绝回答任何问题。
威科集团高管克里斯蒂·德罗林格于3月向KFF健康新闻一般性介绍了Sentri7软件，她表示该软件需求旺盛，因为许多医院都在努力保障药物安全。
德罗林格称，Sentri7会监测约60个“风险归因点”，识别出需要医院员工进一步调查的危险信号。
“这相当令人担忧，”德罗林格在谈及普遍存在的药物盗窃问题时说道，“每个卫生系统、每个医疗机构在某个时刻都曾发生过药物转移——而且可能现在仍在发生。”
“未来的发展方向”
药物转移是美国医疗机构普遍面临的难题。它可能导致患者无法获得药物，或是拿到被血液传播疾病污染的药品。根据非营利组织医疗保健转移网络的数据，估计多达15%的医护人员至少有过一次药物转移行为。
美国疾病控制与预防中心的数据显示，自1985年以来，药物转移已与至少13起疾病暴发事件相关联，导致200多人感染，其中大多为丙型肝炎。
为防止此类情况发生，医院试图对每一片药片或每一瓶药物从配药到交付给患者的全过程进行追踪，方法是对比电子药物柜的数据和患者的健康记录。
医护人员过去曾手动完成这一繁琐流程，但在过去十年里，这项工作已 largely 由反药物转移软件自动化完成。经过多年的合并和收购，目前有两款程序主导了该行业：威科集团的Sentri7和Bluesight公司的ControlCheck。两款软件均融入了人工智能技术。
“这无疑是未来的发展方向，”药物转移专家公司Diversion Specialists所有者卢克·奥弗迈尔说道。
据Bluesight公司称，超过1500家医院使用ControlCheck软件。威科集团表示，另有700家医院使用Sentri7临床监测项目，其中可包含其药物转移监测软件。
两家公司均未公布其软件的价格。约翰·霍普金斯大学的药物安全官员史密斯表示，医院购买这些“昂贵的技术”是因为一起严重的药物转移案件可能导致美国药品执法局处以数百万美元的罚款。
“它们不会承诺投资回报，”史密斯说道，“它们承诺的是成本规避。”
2022年，由美国国立卫生研究院资助的一项同行评议研究发现，当时名为Flowlytics的Sentri7软件，比现有方法更快地发现药物转移行为。该研究的主要作者曾任职于Sentri7此前的所有者Invistics公司。
根据该研究，研究人员通过让软件梳理两家医院两年间的药物数据，以寻找已知存在药物转移行为的22名护士，对该软件进行了测试。
研究称，该程序不仅找到了所有这些护士，而且比人类更快地发现了他们，快的仅一周，慢的则达一年半。
但在埃尔兰格医院，是人类首先发现了异常迹象。
根据护理委员会的命令，同事们报告称，史蒂文森在2025年6月30日左右“在手术中心值班时”表现出意识受损。
命令中称，史蒂文森“言语含糊不清、看起来极度疲惫、被看到闭着眼睛站着且身体摇晃、直立站立时头部点头，似乎难以睁开眼睛”。
在接受州调查人员询问时，史蒂文森承认，他从2025年3月开始转移“本应在手术后被废弃的未使用芬太尼”，命令中称。史蒂文森表示，起初他每周使用一到两次这些剩余芬太尼，到当年6月时“增加到每日使用”。
埃尔兰格医院审计了史蒂文森在那四个月里的配药记录。根据命令，该软件有大约五次未标记出药物缺失的情况。
命令还补充称，医院发现“药物配药和废弃文件之间存在更多不一致之处，本应被自动监测系统标记出来”。
护理委员会在命令中给出了一种可能的解释，称Sentri7在埃尔兰格医院处于“初始学习阶段”，但未提供细节。
在一次采访中，未具体谈及埃尔兰格医院事件的德罗林格表示，Sentri7并没有“学习阶段”，因为在新医院部署该软件时，会先用9到12个月的历史数据对其进行训练。
约翰·霍普金斯大学的史密斯提出了另一种理论。
在一次采访中，史密斯表示，根据他使用人工智能药物转移监测软件的经验，该软件在监测急诊室和重症监护病房方面效果显著，但在手术室则不然，因为那里的药物配药和记录方式有所不同。
史密斯说，这些区域对人工智能来说更难追踪，因此需要人类进行更密切的监控。
“我们有专门负责配合这款软件工作的人员，”史密斯说道，“软件只是其中一部分，但如果你完全依赖软件来提供所有信号，你就会漏掉一些东西。它不可能做到百分之百准确。”
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At a Tennessee hospital, a nurse stole fentanyl and AI missed it, state records say
2026-06-01T05:00:04-0400 / CBS News
About a year ago at Erlanger Baroness, the largest hospital in Chattanooga, anesthesia staff noticed that a nurse was slurring his words and struggling to stay awake while on duty in the surgery center, according to a Tennessee Board of Nursing consent order.
In the days that followed, the nurse failed a drug test and was fired, the order states. The nurse later admitted that for months he had pilfered and abused fentanyl left over after surgeries, sometimes daily, according to the order.
Under most circumstances, this would be a routine case of what is known as “drug diversion,” the unlawful taking of controlled substances from healthcare facilities — believed to be so widespread that it occurs at just about every U.S. hospital.
But the Erlanger case stands out because a high-tech watchdog was supposed to be on guard.
The hospital uses the newest line of defense against drug diversion: Sentri7, medication-monitoring software powered by artificial intelligence and designed to detect missing drugs faster than any human can. But for months at Erlanger, Sentri7 failed to raise alarms, overlooking missing drugs and other “inconsistencies” that “should have been flagged,” the nursing board’s order states.
The Erlanger case, which has not been previously reported, offers a rare glimpse at an apparent failure of AI drug diversion software used in hundreds of U.S. hospitals with little transparency or oversight. Healthcare facilities are not required to disclose their implementation of this kind of software or report malfunctions to anyone, so there is no full account of how widely these programs are used or how often they fail.
Erlanger Baroness, also referred to as Erlanger Medical Center, declined to comment on its use of Sentri7 or on the diverted drugs. André Rebelo, a spokesperson for the health division at Wolters Kluwer, the Dutch technology company behind Sentri7, declined to answer questions about what happened at Erlanger but said the company remained “confident in our software.”
Little transparency
David Rastall, a Johns Hopkins Medicine neurologist and AI researcher, said that because AI technology is heavily proprietary and hospital officials often don’t understand how it works, this lack of transparency allows for errors to be buried rather than fixed. That means errors could be repeated at other hospitals, he said.
“The ideal for patients, caregivers, and hospitals systems would be,” Rastall said, “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 lost or stolen drugs. Hospitals can also report stolen drugs to state health agencies, which license medical professionals and investigate wrongdoing.
But these reports are not required to include details about any AI software involved, according to interviews with three drug diversion prevention experts. In interviews, all said they had never seen an AI failure publicly documented like the apparent one at Erlanger.
“I’ve never myself seen these technologies be called out in that specific way,” Jacob Smith, a pharmacist in charge of drug security at Johns Hopkins Medicine, said of the apparent Sentri7 failure. “It doesn’t make sense to me how you could miss it.”
Smith and other experts said the Erlanger case also raises questions because the theft of leftover drugs is one of the most well-known methods of diversion. And fentanyl, a painkiller that can be 50 times as strong as heroin, is one of the most common targets.
Terri Vidals, the founder of Rxpert Solutions, questioned whether the Erlanger case was the result of user error instead of malfunction.
“This is the most basics of basics for this software,” Vidals said. “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 apparent Sentri7 failure at Erlanger was revealed by the Tennessee Department of Health in a routine release of state disciplinary orders in December. Among those records was the Board of Nursing order, which summarizes a state investigation into nurse anesthetist John Stevenson, who settled the case against him by signing the document in November.
Stevenson declined to comment through his attorney. He has not been charged with any crime related to the Erlanger case. The nursing board put his license on probation while he went to drug counseling.
Bill Christian, a spokesperson for the Department of Health and Board of Nursing, declined to comment on the Erlanger case or Sentri7. In response to public records requests, the Department of Health and the Tennessee Health Facilities Commission each said it possessed no other documents about the apparent Sentri7 failure at Erlanger.
Erlanger spokesperson Charlie Milburn said earlier this year that the hospital had prepared a written statement about its use of Sentri7 in response to questions from KFF Health News.
That statement was never released.
“Our legal team is debating whether this is something we want to talk about at all,” Milburn said in a March email, before later declining to answer any questions.
Kristy Drollinger, a Wolters Kluwer executive who spoke generally about Sentri7 to KFF Health News in March, said the software is in high demand because so many hospitals have struggled to secure their drugs.
Sentri7 monitors about 60 “attributions of risk” that identify red flags for further investigation by hospital employees, Drollinger said.
“It’s pretty scary,” Drollinger said 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 challenge in U.S. medical facilities. It can lead to patients not receiving medication or getting drugs that are contaminated with blood-borne diseases. It’s estimated as many as 15% of all healthcare workers divert drugs at least once, according to the nonprofit Healthcare Diversion Network.
Diversion has been linked to at least 13 disease outbreaks — causing more than 200 infections, mostly of hepatitis C — since 1985, according to the Centers for Disease Control and Prevention.
To prevent this, hospitals attempt to track each pill or vial from the moment it is dispensed to the moment it is given to a patient, by comparing data from electronic medication cabinets and patients’ health records.
Hospital staff once performed this painstaking process manually, but in the past decade the task has become largely automated by anti-diversion software. After years of mergers and buyouts, two programs now dominate the industry: Wolters Kluwer’s Sentri7 and Bluesight’s ControlCheck. Both incorporate AI.
“It’s definitely the way of the future,” said Luke Overmire, owner of Diversion Specialists.
More than 1,500 hospitals use ControlCheck, according to Bluesight. An additional 700 use Sentri7 Clinical Surveillance programs, which can include its drug diversion software, according to Wolters Kluwer.
Neither company publishes the price of its software. Smith, the drug safety official from Johns Hopkins, said hospitals purchase these “expensive technologies” because a disastrous diversion case could result in a multimillion-dollar fine from the DEA.
“They don’t promise a return on investment,” Smith said. “They promise cost avoidance.”
In 2022, a peer-reviewed study funded by the National Institutes of Health found that Sentri7, then known as Flowlytics, could uncover drug diversion faster than existing methods. The study’s primary author worked for Invistics, the company that previously owned Sentri7.
According to that study, researchers tested the software by having it comb through medication data spanning two years and 10 hospitals in search of 22 nurses who were already known to have diverted drugs.
The program not only found them all, the study states, but found them faster than humans by as little as a week and as much as a year and a half.
At Erlanger, the humans spotted the signs of trouble first.
According to the Board of Nursing order, co-workers reported that Stevenson appeared impaired “while on duty in the surgery center” on or around 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,” according to the order.
When questioned by state investigators, Stevenson admitted that he began diverting “unused fentanyl that would otherwise have been wasted after surgical procedures” in March 2025, according to the order. Stevenson said he used the fentanyl waste once or twice a week at first, then “increasing to daily use” by June of that year, the order states.
Erlanger audited Stevenson’s dispensing record over those four months. It found approximately five instances when Sentri7 didn’t flag missing drugs, according to the order.
It adds that the hospital found “additional inconsistencies between drug dispensing and waste documentation that should have been flagged by the automated monitoring system.”
One possible explanation is provided by the Board of Nursing, which said in the order that Sentri7 was in its “initial learning phase” at Erlanger, though the board provided no details.
In an interview, without discussing Erlanger specifically, Drollinger said Sentri7 has no “learning phase,” because it is trained on nine to 12 months of historical data when implemented at a new hospital.
Smith, of Johns Hopkins, had another theory.
In an interview, Smith said his experience with AI drug diversion software had led him to believe that it is effective at monitoring emergency rooms and intensive care units but less so in operating rooms, where drugs are dispensed and charted differently.
These areas can be harder for AI to track, Smith said, and therefore require humans to keep a closer watch.
“We’ve got people whose entire job is to work with this software,” Smith said. “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%.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
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