CDC Report Links Drug Diversion by Hospital Workers to Bacterial & Viral Infections in Patients
CDC researchers describe the growing problem of in-hospital infections in the United States being caused by drug thefts and contaminated syringe re-use by hospital employees. In the last 10 years over 30,000 patients have been exposed to pathogens via drugs diverted by infected medical professionals.
A new report by CDC researchers Melissa K. Schaefer, MD, Joseph F. Perz, DrPH, describes how a few bad actors in medical settings can negatively affect the health of thousands of patients. In “Outbreaks of Infections Associated With Drug Diversion by US Health Care Personnel” Schaefer and Perz examined hospital records for patient infections in the United States over the last 10 years. In doing so, they found that drug diversion, or theft of pain medication by just 6 medical workers had exposed 30,000 patients to either bacterial infections or Hepatitis C virus (HCV) infections.
The incidents (from the CDC report)
Texas (2004) – 16 surgical patients develop symptoms after exposure to HCV. Testing of hospital personnel who had contact with the infected patients turned up a certified registered nurse anesthetist (CRNA) who tested positive for HCV. The infected nurse was suspended from work but no charges were filed. The nurse in question moved on to work at hospitals in other states and was not caught until 2009, at which point the nurse admitted to stealing portions of Fentanyl for personal use. Nurse was sentenced to 41 months in prison and had exposed 1,859 patients in several states to HCV.
Illinois (2006) – 9 surgical patients develop specialized bacterial infections shortly after administration of morphine by a patient-controlled dispensing pump. Statistical analysis linked initial starting of pumps to a single nurse who worked at the hospital. No charges were filed as the nurse resigned upon being notified of the association.
Florida (2008) – 5 interventional radiology patients were found to have been exposed to HCV during their hospital stay. Testing of employees revealed that one radiological technician was infected with a genetically similar strain of HCV. The technician admitted that his habit was to take Fentanyl syringes ready for patient administration, self-inject, refill the syringes with saline, then replace the syringes for use in surgery. The technician pled guilty to tampering with a consumer product resulting in death, tampering with a consumer product resulting in serious bodily injury, and stealing fentanyl by deception and, in 2012, was sentenced to 30 years in prison.
Colorado (2009) – 18 surgical patients developed HCV infections after going through surgical procedures at the hospital. Hospital administration identified that a surgical technician who had recently suspended for drug diversion was HCV-positive and the likely culprit. The technician admitted to taking prefilled syringes of fentanyl from surgical carts and self-injecting, then replacing the fentanyl with saline solution before adding them back onto the surgical cart. The technician pled guilty to tampering with a consumer product and obtaining a controlled substance by deception and, in 2010, was sentenced to 30 years in prison.
Minnesota – (2011) 25 patients developed a specialized bacterial infection after treatment with hydromorphone via a patient self-dispensing pump. A review of automated dispensing logs revealed a nurse who accessed the bags of medication far more often than any other employee. The nurse in question admitted to drawing hydromorphone from treatment bags held in lock boxes, then replacing the missing liquid with saline solution. The nurse was removed from practice and, in 2012, pled guilty to obtaining a controlled substance by fraud and was sentenced to 2 years in prison.
New Hampshire, Kansas, and Maryland – (2012) 45 cardiac catheterization/interventional radiology patients from 4 different hospitals in 3 states developed HCV infections after treatment. The infections were eventually traced to a travelling radiology technician who was infected with HCV. When finally confronted, the technician admitted to self-injecting narcotics, and refilling the syringes with saline solution before replacing them the procedure area at the hospitals over the last several years. The technician pled guilty to tampering with a consumer product and obtaining controlled substances by fraud and, in 2013, was sentenced to 39 years in prison.
Dr. Eric Sampson Senior Science Advisor for CDC Foundation will be speaking at Interchange 2014, discussing how to measure the extent of patient impact from counterfeit and diverted drugs. Learn how drug diversion is threatening the health of U.S. patients. Register for Interchange 2014 today!