CHATTANOOGA — John Stevenson, a nurse anesthetist at Erlanger Baroness Hospital in Chattanooga, admitted to diverting fentanyl and had his nursing license placed on probation by the Tennessee Board of Nursing in November after failing a drug test. The disciplinary action followed observations by anesthesia staff approximately a year ago that Stevenson was slurring his words and struggling to stay awake while on duty in the surgery center.

According to a consent order from the Tennessee Board of Nursing, Stevenson admitted to pilfering and abusing leftover fentanyl from surgeries for months, sometimes on a daily basis. He was fired from Erlanger Baroness after failing a drug test and subsequently signed the consent order, which placed his license on probation while he undergoes drug counseling. Stevenson has not been charged with any crime related to the incident.

The case revealed a failure in Sentri7, an AI-powered medication-monitoring software used by Erlanger Baroness to detect missing drugs. According to the board’s order, Sentri7 failed to raise alarms for months despite missing drugs and other “inconsistencies” that “should have been flagged.” The apparent software failure became public in December through a routine release of state disciplinary orders.

Jacob Smith, pharmacist in charge of drug security at Johns Hopkins Medicine, expressed skepticism about the software’s reported failure. “I've never myself seen these technologies be called out in that specific way,” Smith said. “It doesn't make sense to me how you could miss it.” He added that hospitals invest in expensive systems like Sentri7 not for return on investment but for “cost avoidance,” as a major diversion case could lead to multimillion-dollar fines from the Drug Enforcement Administration.

David Rastall, a Johns Hopkins Medicine neurologist and AI researcher, said proprietary AI systems often lack transparency, which can prevent errors from being addressed. “The ideal for patients, caregivers, and hospital systems would be, when an AI is found to be making some type of error, that becomes very transparent and public,” Rastall said.

Erlanger Baroness, also known as Erlanger Medical Center, declined to comment on its use of Sentri7 or the drug diversion incident. The Tennessee Department of Health and Board of Nursing also declined to comment, and public records requests yielded no additional documents about the Sentri7 failure. Hospitals are not required to disclose details about AI software when reporting lost or stolen drugs to state agencies or the DEA.