By Gary Evans, Executive Editor, AHC Media
A nurse stealing morphine by replacing it with saline in a medication vial might 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 was followed by the injury of infection, which proved fatal in one patient. That scenario is under investigation at a Wisconsin hospital, the latest in a series of outbreaks linked to drug-diverting healthcare workers. (See second story that follows.)
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 Centers for Disease Control and Prevention (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 might 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 the 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 occurring, as many healthcare-associated infections (HAIs) are not being tracked back to drug diversion activity that is apparently rampant in the healthcare system. Joseph Perz, PhD, co-author of the study and team leader of quality and safety in the CDC’s Division of Healthcare Quality Promotion, says, “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. 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.”
If you look hard enough for diverters, you are highly likely to find them, says 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.
“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.” (See story on injection safety, below.)
- Schaefer MK, Perz JF. 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.