Incident at Erlanger Baroness Hospital

In June 2025, anesthesia staff at Erlanger Baroness Hospital (Chattanooga, Tennessee) observed nurse anesthetist John Stevenson appearing impaired—exhibiting slurred speech, drowsiness, and head nodding. Stevenson was fired after failing a drug test. He later admitted to diverting and abusing fentanyl leftover after surgeries from March 2025 onward, increasing to daily use by June 2025.

Failure of AI Monitoring Software

The hospital employed Sentri7, a medication-monitoring AI software designed to detect missing drugs. According to a Tennessee Board of Nursing consent order, Sentri7 failed to flag missing drugs and other inconsistencies over the four-month period.

The nursing board order stated that Sentri7 was in its "initial learning phase" at the time. Wolters Kluwer, the company behind Sentri7, declined to discuss the case but said the software has no learning phase, as it is trained on historical data before implementation.

Expert Observations

David Rastall (Johns Hopkins Medicine neurologist and AI researcher) noted that lack of transparency in AI systems can lead to errors being repeated.

Jacob Smith (Johns Hopkins drug security pharmacist) expressed surprise that the software missed such a common diversion method and suggested that AI monitoring may be less effective in operating rooms.

Terri Vidals (Rxpert Solutions founder) speculated that user error might have contributed.

Regulatory Context

The Drug Enforcement Administration requires hospitals to report lost or stolen drugs confidentially, but no mandate exists to disclose AI software involvement or failures.

The case was revealed through a routine release of state disciplinary orders by the Tennessee Department of Health. Stevenson's nursing license was placed on probation while he attended drug counseling.