Powerful painkillers, sedatives and other addictive drugs went missing from UT Southwestern Medical Center in Dallas over three years. In that time, two nurses died of overdoses, the hospital had two other nurses arrested for stealing drugs, and officials met to discuss internal flaws in tracking dangerous drugs.

Yet dozens of times from 2016 to 2018, when drugs were lost or possibly stolen, UT Southwestern didn't notify the federal Drug Enforcement Administration, which depends on such disclosures in its battle against the nation's opioid epidemic, The Dallas Morning News found.

The DEA is investigating UT Southwestern, and a federal agency that oversees hospital safety has cited the university for not filing reports with the DEA.

UT Southwestern said it didn’t disclose cases that involved documentation errors but maintains it acted in accordance with applicable regulations. Hospital officials said they now follow “a more stringent interpretation” of federal law and that they’ve taken steps to better track the powerful drugs they give patients.

Patricia Norman, a nurse at UT Southwestern's Clements hospital, died after overdosing on fentanyl in the hospital in December 2016. She was 32. (Courtesy of Jeri Van)

The university said the diversions did not result in lapses in patient care. But it said that “missteps in timely reporting” can erode public trust. The university said it has learned from past instances of diversion and remains dedicated to doing better.

Tight security protects patients as well as health care workers who may be vulnerable to addiction.

"We hope the public recognizes that there is no effort to intentionally circumvent any reporting mandates nor to permit an environment in which diversion is successful," the university said in a statement. (Click here to read more from UT Southwestern on this issue.)

The News obtained documents showing that in some cases between 2016 and 2018, UT Southwestern had signs that opioids and other drugs had been pilfered.

In another instance, hospital employees didn’t realize an opioid was missing, even as a nurse fatally overdosed on the same kind of drug.

The News reported last year that two nurses died after overdosing on fentanyl at UT Southwestern's William P. Clements Jr. University Hospital, where they worked. That story prompted a surprise inspection by the federal Centers for Medicare and Medicaid Services. In January, the agency faulted UT Southwestern for not alerting the DEA to numerous cases in which controlled substances went missing.

After the inspection in January, UT Southwestern filed 31 reports with the DEA going back as far as three years. Since then, the university has filed additional reports with the DEA.

Two nurses arrested

In January 2016, a nurse was suspected of stealing fentanyl and other prescription drugs at Clements hospital. A supervisor told campus police that a coworker on multiple occasions had seen the nurse sign out patients’ drugs and take them into a bathroom. Colleagues had found empty syringes in nearby staff restrooms, according to a police report.

The nurse, Aaron Bradley Hudson, was later arrested and he pleaded guilty to fraudulently obtaining drugs.

But UT Southwestern did not report the drug theft to the DEA until after the federal hospital inspection this year.

A UT Southwestern employee told the federal inspector that at the time, it wasn’t clear the medications had been stolen.

The medical center did not explain the conflicting accounts. It said it does not comment on individual employees or patients, citing the need to protect their confidentiality.

In 2017, UT Southwestern did not report information to the DEA in another case.

A supervisor at a university cancer clinic noticed a nurse looking drowsy and falling asleep during conversations, according to court records.

Campus police determined the nurse had removed an opioid called Dilaudid from a medicine cabinet more than 240 times in three months without a doctor’s approval. In one instance, the nurse withdrew the drug under the name of a patient who had been discharged four months earlier. In another, she signed out drugs for a patient who had died, according to court records.

The university reported the nurse to the state nursing board, and campus police arrested her. Last year she entered drug court, a treatment and counseling program for first-time drug offenders. She recently graduated and is eligible to have her case expunged, according to the Dallas County District Attorney's office. The News is not identifying her because she has not been charged with a crime.

UT Southwestern reported just one of the thefts to the DEA, records show, but did not say why it hasn’t reported the others.

Overdose deaths

When nurse Iyisha Keller died last year inside the hospital of a fentanyl overdose -- and her patient’s fentanyl could not be found -- UT Southwestern didn’t initially tell the DEA.

The campus police department investigated Keller’s death last year. UT Southwestern said it found no evidence linking the death to hospital drugs, and that the source of those fatal drugs could not be determined.

In April 2018, a second Clements nurse died after overdosing on fentanyl in the hospital. Iyisha Keller was 36. (Courtesy of the Keller family)

In fact, new records UT Southwestern released this year offer evidence suggesting Keller did get the fentanyl from the hospital.

Keller was caring for a patient in intensive care who had a fentanyl IV bag, records show. She overdosed during her shift.

The university had the liquid in the bag tested. It came back negative for fentanyl.

That scenario suggests tampering, said Kimberly New, a nurse and lawyer in Tennessee who advises hospitals on preventing drug thefts. The nurse could have removed the fentanyl from the IV bag and replaced it with another liquid so no one would notice, she said.

“If I had something that was supposed to contain fentanyl and it didn’t, I would report that as theft,” New said.

About eight months later, during the federal hospital inspection, UT Southwestern employees said they did not realize any drugs were unaccounted for. After the inspection, the university reported the potential theft to the DEA and told the agency it had imposed changes that make it more difficult to tamper with IV tubing.

A year and a half earlier, nurse Patricia Norman had died from a fentanyl overdose at the hospital. UT Southwestern told the DEA at the time that fentanyl was stolen on the day she died in 2016, but did not say whether it was connected to her.

As with Keller, UT Southwestern has said it found no evidence linking Norman’s death to hospital drugs and could not determine the source of the medications that killed her.

New records from the hospital inspection show UT Southwestern actually had connected the fentanyl missing from a patient’s IV bag to Norman’s case.

Other missing drugs

In the months leading up to Norman’s death, records show nine other instances in which she signed out medication for patients, but the hospital could not account for the drugs.

Taken individually, the missing medications might not have stood out: Four teaspoons of hydrocodone one day in early September, for instance, followed by small amounts of fentanyl or Dilaudid on three more days that month.

The DEA requires pharmacies to report "significant losses" and thefts of controlled substances. The agency offers guidance on what it means by significant: A "pattern of losses over a specific time period" can be a red flag.

UT Southwestern did not tell The News whether it knew about the discrepancies before Norman died. But records show that soon after her death, UT Southwestern was aware of them.

Even so, the university didn’t report the disparities to the DEA until after the hospital inspection.

Experts say that in such a case, the DEA should be notified.

“I would have advised them to report that,” said Larry Cote, a former DEA lawyer who handled drug diversion cases and now works in private practice. “In this case you err on the side of caution.”

Hospital inspection records show a similar series of discrepancies from last fall -- employees signed out drugs for patients 20 times but couldn’t account for the medicines. It’s unclear whether UT Southwestern figured out what happened to those doses. None were reported to the DEA until after the hospital inspection. UT Southwestern did not discuss them.

The federal hospital inspection mentioned only those cases from last fall and the three published in The News. The university did not say whether it has reviewed other time periods.

Authorities are investigating

The scope of the DEA’s investigation is unclear and the Justice Department, which oversees the DEA, and UT Southwestern declined to comment on it.

The News has learned through interviews with multiple sources that the agency has met with people who knew some of the nurses.

UT Southwestern said it is always improving the way it tracks and secures dangerous drugs.

The university said it has hired directors to oversee opioid and pharmacy safety, increased education and strengthened surveillance, among other ongoing efforts. Several nurses resigned after the university questioned them about their handling of controlled substances.

Other efforts have fallen short.

After Norman died, a committee tasked with stopping and investigating drug thefts recommended tracking certain nurses more closely and counting all narcotics each week.

But last year, the committee found the weekly tallies weren’t happening, and that it could take up to a month to discover discrepancies.

During the January federal hospital survey, the inspector entered a room where a patient was receiving fentanyl through an IV bag. The tamper-proof tubing was in place, but the bag itself was not secure. The inspector noted that there was nothing to prevent the bag from being taken.