The Iowa Board of Pharmacy has cited and warned a MercyOne hospital pharmacy after a pharmacy technician diverted 330 tablets of a controlled stimulant undetected for nearly two years.
MercyOne Dubuque (Iowa) West Pharmacy failed to maintain controlled-substance accountability and did not verify that its physical drug inventory matched its expected inventory, according to a July 7 settlement order.
The pharmacy implemented a new controlled-substance accountability policy in place in October 2025. Two months later, it discovered that a pharmacy technician had diverted phentermine 37.5-milligram tablets, a Schedule IV stimulant. As the pharmacy rolled out the new procedure, it found additional discrepancies in prior years, totaling 330 phentermine tablets.
The thefts went undetected because the pharmacy did not follow accountability rules that changed in July 2022 and did not run audits at the required frequency, the board said. Audits conducted between August 2023 and June 2025 missed the diversion because the technician manually adjusted the inventory system so the physical count matched the expected count at the time of each audit.
“In 2025, following the identification of a diversion incident involving a former pharmacy technician, the organization conducted a thorough review, implemented enhanced controlled substance accountability procedures and strengthened auditing and oversight processes,” a spokesperson told Becker’s. “MercyOne cooperated fully with the Iowa Board of Pharmacy throughout its review and has addressed the findings outlined in the board’s citation.”
The board cited the pharmacy under Iowa Administrative Code rules for controlled-substance accountability and inventory reconciliation. To resolve the charges, the pharmacy agreed to a citation and warning and to comply with all state and federal pharmacy laws. The board said it would report the order to the National Association of Boards of Pharmacy.
Board Chairperson Erik Maki, PharmD, signed the order July 7.
Drug diversion by healthcare workers remains a persistent controlled-substance compliance risk for hospital pharmacies, where gaps in routine auditing can let losses go undetected for years.
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