By Gary Evans, Executive Editor
A nurse stealing morphine by replacing it with saline in a medication vial may not have realized she was colonized with Serratia marcescens, a gram-negative bacteria that would soon find its way into the bloodstreams of a cluster of patients administered the contaminated solution. The insult of denied pain treatment is followed by the injury of infection, which proves fatal in one patient.
That is the scenario currently under investigation at a Wisconsin hospital, the latest in a recurrent series of outbreaks linked to drug-diverting healthcare workers. (Please see “Serratia outbreak linked to drug diversion” later in this issue.)
More often, these cases involve hepatitis C virus, and it is particularly shocking to see how many patients can be endangered by a single healthcare worker. Over the past decade, outbreak investigations have documented more than 100 infections and nearly 30,000 potentially exposed patients stemming from drug diversion in U.S. healthcare facilities, a CDC study reveals.1
As disturbing as those numbers are, it should be noted at the outset that while protecting patients is paramount, nurses also emphasize the ethical obligation to try to get their addicted colleagues into treatment: “Drug diversion is a symptom of the disease of addiction … a treatable disease.”2
Encouraging healthcare workers with an addiction problem to seek treatment may be one of the best ways to save a caregiver’s career before the disaster of an outbreak — the event that typically reveals the diverter.
“[Infection preventionists] would probably be the ones that would see an unusual cluster of infections and start investigating,” says Melissa Schaefer, MD, co-author of the study and a medical officer in CDC’s division of healthcare quality promotion. “But ideally, we don’t want it to get to a cluster of infections or an outbreak. That brings up the need for a really strong detection surveillance system in place — a response mechanism so that when there’s an abnormality you can jump on it.”
The reported outbreaks of infections related to drug diversion by healthcare workers represent only a small snapshot of what is actually occurring, as many healthcare associated-infections (HAIs) are not being tracked back to drug diversion activity that is apparently rampant in the healthcare system.
“Making the connection between unexplained or difficult-to-detect infections on the one hand, and illicit, concealed drug diversion activities, on the other hand, is extremely difficult,” says Joseph Perz, PhD, co-author of the study and team leader of quality and safety in the CDC’s division of healthcare quality promotion. “Our review also does not in any way adequately reflect the frequency of diversion by healthcare personnel in the United States. It has been reported that more than 100,000 U.S. doctors, nurses, technicians, and other health professionals struggle with abuse or addiction. Prescription drugs and controlled substances such as oxycodone and fentanyl are often involved.”
The experience of drug diversion expert Kim New, RN, JD, an independent consultant who previously founded a program to detect diverters at the University of Tennessee Medical Center (UTMC) in Knoxville, suggests if one looks hard enough for diverters, she is very likely to find them.
“Initially, when I started the program [at UTMC] I was catching three or four per month and then it leveled out to one to two per month and pretty much stayed there,” she says “I have no reason to believe that what I experienced in that medical center is any different than what [is happening] at similar institutions. In fact, I work extensively with hospitals and health institutions across the country on this topic and I have heard from more than one academic medical center of approximately the same size that they were catching the same [number of diverters] when they had an aggressive program.”
THE COST OF SILENCE
Compounding the problem, hospitals fearing liability or even the perception of some culpability in drug diversion incidents may be reluctant to report and prosecute diverters. Though this pattern may finally be changing, typically diverters are fired or allowed to resign — which leaves them free to find work in another facility.
“Unfortunately, the cases that fall through the cracks are the ones that aren’t prosecuted,” New says. “Most institutions that I am aware of will only provide dates of employment when asked for a reference.
“A flagrant example of the price of this silence was discovered in a New Hampshire hospital in 2012, when an HCV-infected traveling radiology technician was linked to a cluster of HCV patient infections. The subsequent investigation uncovered a large HCV outbreak spanning several years, involving more than a dozen hospitals, and affecting thousands of patients in eight states. The technician was stealing syringes filled with narcotics, self-injecting, refilling them with saline, and placing them back into the procedure area, the CDC investigators reported.
“In the New Hampshire outbreak, we absolutely documented transmission in other hospitals in other states from this serial offender,” Schaefer says.
The tech, David Kwiatkowski, 35, was sentenced to 39 years in prison after listening to witness after witness describe how his actions harmed them or loved ones.
“I don’t blame the families for hating me. I hate myself,” Kwiatkowski said at the Dec. 2, 2013 sentencing in Concord, NH.3 Still, this was someone who once had thoughts of helping others, creating a dilemma for 71-year-old victim Linda Ficken, who was infected with HCV at a Kansas hospital where Kwiatkowski worked. Undergoing a cardiac catheterization in 2010, Ficken recalled the tech standing by her bedside during the procedure to apply prolonged pressure to a bad bleed at the catheter insertion site in her leg.
“On one hand, you were saving my life, and on the other hand, your acts are a death sentence for me,” she said at the sentencing. “Do I thank you for what you did to help me? Do I despise you for what your actions did and will continue to do for the rest of my life? Or do I simply just feel sorry for you being the pathetic individual you are?”
That outbreak has resulted in ongoing lawsuits involving the staffing agencies that employed the technician, as downstream facilities argue they should have been informed of the risk of hiring him. The multistate outbreak of HCV infections identified in New Hampshire drew national attention, and is the most recent example of a healthcare worker being able to repeatedly gain employment — even after diversion was suspected or documented at previous worksites.
“Many institutions fear negative publicity — they fear civil and regulatory liability in these cases,” New says. “That is a legitimate concern, but we all have to do the right thing, and sometimes that means taking those risks. In order to protect patients from harm, we do have to report these things. There have been highly regarded facilities that have diversion cases that result in patient harm and then they are characterized in the media as being somehow at fault. Unfortunately, these cases can happen to anyone.”
One of the states caught up in the large HCV outbreak (Maryland) has labor immunity provisions that should shield institutions who report healthcare worker diversion incidents in good faith. In light of the outbreak, however, state investigators recommended additional legislation clarifying liability protection related to disclosure of negative references to prospective employers.4
“To protect patients from harm, there will have to be some way to promote all institutions reporting appropriately,” New says. “[Liability] barriers are going to have to be addressed in order to get everyone to report uniformly. There are medical board and nursing board implications. The nurse practice act in every state requires that if a nurse is aware of any illegal or incompetent practice then they have to report that or they are in violation.”
The tide may be turning on this issue, as more hospitals are pursuing prosecution rather than simply firing workers when diversion is uncovered, New says.
“From an infection prevention standpoint, the advantages of reporting to law enforcement are that many times there can be a discoverable deposition for that person much sooner than if you just report them to the nursing board,” New says. “Sometimes nursing board [investigations] can be very protracted, so subsequent employers wouldn’t know what has happened. If law enforcement gets involved and they pursue an arrest and criminal prosecution, many times that information could be discovered by a subsequent employer.”
Of course, infection preventionists play key roles in detecting outbreaks related to drug diversion, but they can also assist in preventing diverters.
“I advocate that infection prevention departments be apprised of every diversion event that occurs within an institution,” New says. “That doesn’t necessarily mean they have to investigate it, but if they keep a database, then later if they find three patients from a particular unit with an unexpected infection they can quickly look at the database and see [if an identified diverter worked in that unit]. You can connect the dots more quickly.”
Also note incidents involving diverted pills, as that healthcare worker may also have sought out injectable medications for personal use, she notes.
“I recommend that every hospital have a formal process, that they have a diversion committee and someone who is managing the day-in, day-out activities of the diversion program. It really is something that requires daily attention,” New says. “It can be someone from pharmacy — many of my clients have a pharmacy tech as their diversion specialist. It can be a nurse, or someone in compliance, auditing, quality, or risk management. One of my clients has an occupational health nurse and a security officer that work together and do this type of surveillance. It really depends on the institution.”
INJECTION SAFETY ISSUES
IPs are becoming more involved in drug diversion prevention as part of the increasing focus on safe use of needles and vials, which was the subject of a Joint Commission sentinel alert5 last year, says Vicki Allen, MSN, RN, CIC, infection prevention coordinator at Beaufort (SC) Memorial Hospital.
“I’m seeing more involvement with infection control just because of the whole exposure situation,” she says. “The Joint Commission [alert] was actually on the misuse of vials, but in talking about it, obviously diversion is one of the misuses of the vial.”
As a result, many hospitals are now emphasizing the proper use of single-dose vials and limiting access to multidose vials that could be contaminated.
“The recommendation is to have single-dose vials whenever possible, and that’s going to decrease the risk that you have multidose vials sitting around that can be accessible to those looking [to divert],” Allen says.
Additionally, the common practice at her facility is for the pharmacy to provide the smallest dose possible for a given patient in the drug-dispensing container, she adds.
“If the patient is ordered morphine, the pharmacist is going to supply the lowest dose vials that they can, keeping the volume as low as possible,” Allen says. “Decreasing the volume of the drug availability is one way we can control it. Another part of that is an audit. Make sure you are doing audits on your units to look for open vials and any kind of red flag that would clue you into some kind of diversion activity or patient exposure.”
With patient safety advocates pushing more involvement of patients and families in their medical care, there are also opportunities to assess pain levels that could raise the possibility of diversion, she adds.
“Taking pain medication away from patients is essentially harming them,” Allen notes. “By involving the patient and their families during rounding, this sort of thing can be addressed, [by asking], ‘Is your pain being controlled?’ You may trigger something — and that’s happening more and more.”
While it does appear that incidences of drug diversion are increasing overall based on media reports and journal articles, that may also be a surveillance artifact of looking harder for signs of diversion activity, she adds.
“It may be just that we are more aware,” she says. “It’s on the radar, so we are looking for it more. Patient safety is such a huge factor now. People are doing audits, more surveillance, mandatory reporting. The other thing is we have more oversight now by CMS.”
In that regard, a recently finalized hospital infection control survey for CMS inspectors does not cite drug diversion specifically, but focuses a lot of attention on the proper use of needles, syringes, and single-dose and multidose vials. Surveyors are instructed to observe injection safety practices in two separate units of the hospital, if possible.
The CMS conditions of participation to protect patients from harm are certainly applicable to drug diversion, which the Joint Commission standards address, and is a felony in every state, New says.
“The standards are out there — there is a regulatory aspect for hospitals to meet, but most of the time, unfortunately, the standards are not specific enough [to require] the hospital to have the ‘ultimate’ program and security measures,” she says.
Regardless, hospitals should provide every incentive to establish strong diversion prevention programs. Patients infected or exposed by drug diverters may be entitled to considerable compensation. Citing the huge sums some juries have awarded to patients infected through injection safety lapses and oversights, a drug diversion expert says similar results may be coming for diversion outbreaks.
“[C]onsider that every healthcare facility that handles divertible drugs is at risk for an unscrupulous healthcare worker not only diverting drugs, but doing so in a manner that could harm patients and others,” Keith Berge, MD, an anesthesiologist at the Mayo Clinic said in an editorial.6 “Then the question becomes not ‘How can we afford a program to prevent and detect drug diversion by healthcare workers?’ but instead ‘How can we afford to not have such a program?’”
The risk of diversion could remain relatively constant in healthcare, given the toxic combination of addiction, medication, and access. “Unfortunately, the plague of drug diversions cannot be fully exterminated because highly intelligent, desperate, and motivated addicts (e.g., addicted nurses and physicians training in or working in drug-rich environments) will continue seeking ways to obtain the highly desirable and abusable drugs housed within healthcare settings,” Berg warned.
- Schaefer MK, Perz J.F. Outbreaks of infections associated with drug diversion by US health care personnel. Mayo Clin Proc 2014;89:878–887.
- Tanga HY. Nurse drug diversion and nursing leader’s responsibilities: Legal, regulatory, ethical, humanistic, and practical considerations. JONA’s Healthcare Law, Ethics, and Regulation 2011;13:13-16.
- Ramer, H. Medical technician sentenced to 39 years in prison for infecting dozens with Hepatitis C. Associated Press. Dec. 2, 2013. Available at: .
- Maryland Department of Health and Mental Hygiene. Public health vulnerability review: Drug diversion, infection risk and David Wiatkowski’s employment as a healthcare worker in Maryland. March 2013. Available at: .
- Joint Commission. Preventing infection from the misuse of vials. Sentinel Event Alert Issue 52, June 16, 2014. Available at: .
- Berge KH, Lanier WL. Bloodstream infection outbreaks related to opioid-diverting health care workers: A cost-benefit analysis of prevention and detection programs Mayo Clin Proc 2014;89:866-868.