In an all-too-familiar scenario, a hospital worker charged with diverting drugs in Colorado had a history moving from hospital to hospital, prompting several other facilities to advise thousands of patients to get tested for bloodborne pathogens.
According to a federal indictment,1 Rocky Allen, 28, a former surgical technologist at Swedish Medical Center in Englewood, CO, has been indicted by a federal grand jury on charges of tampering with a consumer product and obtaining a controlled substance by deceit. On January 22, 2016, Allen allegedly took a syringe containing fentanyl citrate and replaced it with a similar syringe containing another substance, the indictment charges.
As a result, Swedish Medical Center has advised some 3,000 patients who had surgery between August 17, 2015, and January 22, 2016, to be tested for HIV, hepatitis B, and hepatitis C. The charges set off patient notifications in several other states and hospitals, some of which had apparently fired Allen for alleged drug diversion. These include two hospitals in Washington state and hospitals in Arizona and California, bringing the total of potentially exposed patients to more than 5,000. According to published reports, Allen has pled not guilty, surrendered his passport, and is out on a $25,000 bail. A judge has ordered him to stay at a halfway house and get drug treatment.
Authorities have confirmed that the worker has a bloodborne infection, but have not identified which one. Typically, these cases involve HCV, but patients are also being advised to be tested for HIV and hepatitis B. There are reports of two former Swedish surgical patients testing positive for hepatitis, but it was not immediately clear if they were infected during care or had pre-existing infections.
Lawsuit filed
On March 8, 2016, former patients at Swedish filed a class action lawsuit (bit.ly/22I7hr0) charging that “despite Rocky Allen’s well-documented drug addiction and erratic and … suspicious employment history, defendants hired him as a surgical technician.” The suit accuses the hospital and its corporate parent of negligence in hiring and failing to properly supervise Allen; failing to take preventive steps to prevent employees from drug diversion, and subjecting patients to significant risk and anxiety by potentially exposing them to a life-threatening bloodborne pathogen.
The suit alleges that an employee at Swedish Medical observed Allen taking a syringe filled with fentanyl and replacing it with another syringe in an operating room. The employee told investigators that Allen walked into Operating Room 5, spoke with other individuals, then went to the Pyxis station, picked up a syringe and replaced it with another one before quickly leaving the room. Allen, who was apparently scheduled to be in Operating Room 12 on that day, later tested positive for fentanyl, the lawsuit alleges.
According to the suit, Christy Berg, a special agent for the FDA, testified on February 19, 2016, that Allen was terminated from numerous jobs for drug related reasons. In 2011, Allen was court-martialed by the United States Navy and plead guilty to making a false official statement, wrongfully possessing approximately 30 vials of fentanyl, wrongly possessing a syringe containing fentanyl, stealing fentanyl and stealing a syringe containing fentanyl, the lawsuit claims.
Other specific incidents cited in the lawsuit include that Allen was fired in June 2013 by Scripps Green Hospital in La Jolla, CA, after he was caught switching a fentanyl syringe with a saline-filled syringe. Scripps said in a statement that it notified the U.S. Drug Enforcement Administration (DEA) after taking the action. However, Allen was able to move and find subsequent employment at John C. Lincoln North Mountain Hospital in Phoenix, where he was fired in September 2014 after testing positive for fentanyl, the lawsuit alleges.
The case is similar to one discovered in a New Hampshire hospital in 2012, when an HCV-infected traveling radiology technician was linked to a cluster of HCV patient infections. (For more information, see the February 2015 issue of Hospital Infection Control & Prevention.) The subsequent investigation uncovered a large HCV outbreak spanning several years, involving more than a dozen hospitals and affecting thousands of patients in 8 states. The technician was stealing syringes filled with narcotics, self-injecting, refilling them with saline, and placing them back into the procedure area, officials reported. He was sentenced to 39 years in prison.
National epidemic
Addicted healthcare workers are a spectrum in a national opioid epidemic that has reached epic proportions. According to public health officials, the number of accidental overdose deaths from prescription opioids has nearly quadrupled from 1999 to 2013. More than 29,000 deaths in 2014 were due to opioids. While the CDC tries to rein in opioid pain treatment misuse and overuse in the public health arena, recurrent cases of drug diversion, patient exposures, and outbreaks underscore that addicted healthcare workers are putting themselves and certainly their patients at risk.
“Travelers and agency workers do tend to be at higher risk,” says Kimberly New, RN, JD, founder of Diversion Specialists in Knoxville, TN. “We know that based on what we see across the country. It’s not that travelers and agency workers are bad; it’s just that people who are intent on diverting get drawn to that type of work because they can hit and run. They can come in move on.”
Indeed, many of the recent diversion events identified by the CDC have involved “technicians — not doctors and nurses,” says Joseph Perz, PhD, team leader of quality and safety at the CDC’s Division of Healthcare Quality Promotion (DHQP).
“Perhaps there are ways to better evaluate these types of healthcare professions when they are applying for work, and be mindful that people who don’t have direct access to the medications may resort to more dangerous practices to obtain them,” he says. “As with this recent Colorado case, the [2012] case in New Hampshire and in several others people are resorting to swapping a ‘decoy’ syringe for a real syringe of fentanyl.”
This type of diversion appears to be increasing as hospitals adopt more oversight on drug supplies, meaning in part that something cannot be taken without being replaced.
“I am on site at hospitals almost every week of the year and I think it is unrecognized and underreported,” New says. “I think that the [overall diversion] incidence is increasing — I really do. Also [increasing is] the incidence of diversion by tampering and substitution. Perhaps one of the reasons why more providers are turning to tampering and substitution is that they know that we have sophisticated analytics and can monitor what is what is taken out of a drug cabinet, so they look for other methods to divert that will remain undetected.”
More than 100 patient infections and nearly 30,000 potentially exposed patients via drug diversion have been reported in U.S. healthcare facilities over the last decade, according to the CDC.2 Regardless of subsequent infection, the patient suffers harm when their medication is stolen and then put at further risk by whatever contagion may be in the dummy syringe. Due to a history of drug use, the diverter is often infected with HCV or other bloodborne pathogens, which may contaminate syringes and solutions and lead to an outbreak among patients.
Disturbingly, the reported outbreaks of infections related to drug diversion by healthcare workers represent only a portion of the actual infections occurring. In the absence of an outbreak and subsequent lookback investigations, many patient infections are not likely to be linked to a drug diversion incident.
“I think that is unsettling and it is reasonable to conclude,” Perz says. “An infection like hepatitis C often has mild or no symptoms during the initial phase, so those are not diagnosed and reported and they are not investigated.”
‘Moral responsibility’
Compounding the problem, hospitals fearing liability in drug diversion incidents may be reluctant to report and prosecute diverters. Typically, diverters have been fired or allowed to resign — which could leave them free to find work in another facility if their history is not detected.
“I think [failure to report] is a big contributor to some of these more devastating patient harm cases,” New says. “Facilities are worried about their reputation, so they don’t report these cases to law enforcement. This is motivated by the fear that there will be negative publicity and regulatory authorities will come in and raise hell. So facilities don’t want to go that route.”
The CDC hopes that by highlighting the threat of drug diversion and the infection risks to patients, healthcare facilities will realize they have a “moral responsibility” to protect patients, Perz says.
“There is never ‘no harm’ in this context,” he says. “If the drug that was intended for the patient did not reach the patient, then they were harmed. But for whatever reason, healthcare facilities — I’m speculating here — [may have] a sense that they don’t have hard evidence, that patients were not harmed in a substantial way or in a way that they can prove, so they kick the can down the road. The easiest course of action may be to fire the person and the healthcare worker may also quit and walk out the door after being identified.”
If diverters are identified they should be removed from the clinical environment, barred access to controlled substances pending further investigation, and tested for bloodborne pathogens, the CDC recommends. The DEA requires healthcare facilities to report theft or loss of a controlled substance within one business day of the incident, using DEA Form 106.
“The medical community and public health at large have work to do to educate institutions about their responsibilities for not just reporting, but for managing these incidents and assessing potential risks to patients including infection risks,” Perz says. “We have been advocating communication from the health departments to the communicable disease programs if there has been tampering with injectable drugs. We really wish we could move the prevention activities upstream to be less reactive.”
That would require in part prosecuting identified diverters or at least making it clear to future employers that a firing was a result of drug diversion. Without proper reporting, diverters may move from facility to facility, continuing to harm patients, New emphasizes.
“Regarding background checks: If cases are reported to law enforcement and they take some action, that can assist subsequent employers,” she says. “Diversion of any amount of a controlled drug is a felony.”
REFERENCES
- U.S. Attorneys Office District of Colorado. Swedish Medical Center Surgical Tech/Technologist Indicted by Federal Grand Jury in Denver on Charges of Tampering with a Consumer Product and Obtaining a Controlled Substance by Deceit: Feb. 16. 2016: 1.usa.gov/1URmh0
- Schaefer, M.K., Perz, J.F. Outbreaks of infections associated with drug diversion by US health care personnel. Mayo Clin Proc 2014;89:878–887
