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Tucson Medical Center says it has reformed policies and paid an $8,000 fine following the unusual overdose death of a 23-year-old female patient.

The death is what the hospital terms a "sentinel event" — an unexpected death or permanent loss of function in a patient that's not related to the natural course of a patient's illness or underlying condition.

Hospital officials are not saying whether the woman's death in November could have been prevented. But they say new measures — including an oxygen-monitoring device on certain patients and tighter restrictions on hospital visitors — should ensure that a similar situation will not reoccur.

The woman died of "acute opiate intoxication," and the autopsy report showed high levels of morphine and Dilaudid were in her system when she died, an autopsy report says.

The drugs compromised the woman's breathing, and an emergency intubation failed.

The mystery to hospital officials is how the woman got the drugs found in her system. The autopsy report says they entered her body after she was admitted to the hospital. She was pronounced dead 55 hours after she arrived — at 4:17 a.m. on Nov. 19.

The woman did have a history of overdosing on drugs, and that's why she was admitted to TMC Nov. 16. She also had expressed suicidal thoughts in the past, the state report says.

But hospital officials say the woman's history has no bearing Tucson Medical Center's role in her death. What's important to them is that the woman should not have died of a drug overdose from drugs that entered her system while under their watch.

Also, officials say such patients — drug addicted and having suicidal thoughts — are extremely common at TMC. They see at least one or more patients like that every day.

Hospital officials say they are certain they did not give the drugs to the woman.

Adding to the puzzling circumstances, the state reports indicate a hospital employee was with the woman at all times during her entire stay.

Most of the time, that employee was what's called a "sitter," someone whose role is to sit and watch patients, but who isn't necessarily a trained medical professional.

Hospital officials conducted an audit that showed that none of the drugs found in the woman's system were missing from their tightly controlled supplies.

"We have no idea how the drugs got into her system. We are very confident they are not from the hospital," said Linda Wojtowicz, TMC vice president and chief nurse executive.

"There were people in her room. But we can't speculate. We simply do not know," Wojtowicz said.

The woman's mother declined to comment.

The Arizona Department of Health Services fined Tucson Medical Center for two major violations related to care of the woman, including a nurse's failure to assess the patient at the beginning of her shift.

The report also says that based on interviews with hospital personnel, sitters and staffers, "do not have a clear understanding of the reason for sitter being there."

"I agree with the fines. They objectively interviewed everyone involved, and I trust that they did the right thing," Wojtowicz said. "I believe the process we have in place will prevent this from happening again."

Since the death, Tucson Medical Center has made several policy changes:

● Tighter controls on the role of sitters and on communication between nurses and sitters.

● Tighter controls on visitors who are at the hospital to see patients with histories of overdoses and suicidal ideation. Those visitors must have their belongings secured while they see the patient.

● Patients with histories of suicidal thoughts and/or attempts and drug overdoses must wear a "pulse oximeter" that attaches to the patient's finger and measures oxygen levels. If the oxygen levels dip below normal, the device makes a loud noise.

Wojtowicz said the hospital has "addressed the issue" of the nurse on duty the day the woman died, though she would not go into further detail, citing personnel concerns.

Hospital spokeswoman Julia Strange stressed that sentinel events are rarely, if ever, the result of one person making a mistake. "It's all part of a systemic process," she said.

The state report says the woman came into the hospital emergency room at 9:04 p.m. Nov. 16. Emergency personnel reported she'd been unconscious and unresponsive when they arrived at her home.

The emergency-room physician's notes said the woman had a history of psychiatric problems, as well as suicidal thoughts, depression and anxiety. She tested positive for benzodiazepines and narcotics and was transferred to the Intensive Care Unit at 4:30 a.m. Nov. 17.

The state report, based on interviews with hospital officials, said the woman was drowsy, lethargic and had slurred speech. At noon that day, she became agitated and pulled out her intravenous access and also refused the help of a machine to aid with her oxygenation and ventilation.

On Nov. 18, she had a mental-health evaluation, and the report says that morning a physician wrote orders for the woman to go to a regular floor with a 24-hour-per-day sitter.

A nurse in the receiving unit that afternoon reported the woman asked for anxiety medications and that she had slurred speech. There's no documentation the woman received anxiety medication.

The nurse overseeing the woman did not document any assessment of her condition when her shift started at 7 p.m.

An assessment completed at 1:48 a.m. Nov. 19 said the woman was drowsy, but responding to verbal stimuli. It described her as "withdrawn" and denying pain.

The nurse did not note any respiratory distress and noted that a sitter was at the woman's bedside. The nurse did not document the woman's vital signs or oxygen saturation levels.

At about 3:20 a.m., the sitter reported that the woman appeared to be dead. A physician reported that cardiopulmonary resuscitation failed, as did an attempt to intubate the woman. She was pronounced dead at 4:17 a.m.