The story of Lauren Lollini and Kristen Parker is a cautionary tale that healthcare workers tempted to divert drugs should consider.

In 2009, Lollini was the innocent patient, admitted to the ED for surgery at Rose Medical Center in Denver. Parker was a surgical tech who would be sitting in a courtroom admitting she was a drug addict the very next year. She currently is serving a 30-year prison sentence for infecting at least 18 patients with hepatitis C virus (HCV). Parker was an HCV carrier and she spread the virus to the patients while swapping out syringes and vials of the opioid fentanyl with saline solution.

It is worth emphasizing that Parker’s later appeal for leniency on the grounds of addiction curried no favor with the judge who handed down her lengthy sentence. Calling her actions “incomprehensible and unconscionable,” the judge said “addiction explains, but never excuses.”1

No doubt contributing to that decision was the bleak testimony of patients who told of chronic illness and awaking from surgery in severe pain. The Parker case rocked healthcare in Denver at the time, but the issue faded from the spotlight in the state until a surgical tech named Rocky Allen was convicted of a similar diversion crime at Swedish Medical Center in Englewood, CO, last year. Now, the state has some of the toughest anti-diversion laws in the country. Last year, Allen was sentenced to 6.5 years in prison for theft of a fentanyl syringe that led to the testing of 2,400 patients at Swedish Medical. No patients were found to be infected, although Allen clearly put them at risk because he was HIV-positive and had previously been implicated in drug diversion.2

Lollini recovered from her HCV infection and is an outspoken advocate of preventing drug diversion in healthcare facilities for the International Health Facility Diversion Association (IHFDA). Now a psychotherapist living near Chicago, she talked to Hospital Employee Health about the difficult journey that began when she lived in Denver and arrived at the ED that day.

HEH: When did you realize something was wrong after the surgery?

Lollini: Probably five or six weeks later, I was really fatigued and nauseous. I couldn’t keep anything down and had some sort of bronchial problems, too, so I thought maybe I just had the flu. I noticed my urine was very dark. The procedure I had gone in for was to remove a kidney stone, so I thought the dark urine was related to that. I called my urologist and said, “Is this normal?”

HEH: Is that when you were told you may be infected with HCV?

Lollini: I have to be honest, I called them several times and could never get a hold of the doctor and could never get them to call me back. The third time that I called someone at the front desk said, “We knew you might call back and we need to ask if you are in any pain.” I said no, I am not in any pain but I feel pretty sick. They said, “You will be fine if you don’t have pain.” They kind of dismissed me.

I finally went to an urgent care center and they took one look at me and said, “Do you realize you are yellow, you’re jaundiced?” I was sent to the emergency room again. Six weeks prior, I went to the ER with a kidney stone and then this time I went back for a series of tests. My [liver] levels were elevated and then the diagnosis of HCV came, ironically enough, on April 1. But it was no joke. I didn’t know what would cause that and what harm it could do. I was a single parent to a one-year-old daughter. Could she be infected? There was so much fear and anger.

HEH: At that point, had the hospital started notifying patients that they may have been exposed?

Lollini: No. Once I was diagnosed with hepatitis C, the questions were: How did this happen? What were your risk factors? I had none. I had a tattoo years and years before that, but had given blood multiple times since then. Then the Colorado Health Department notified me because I had an infectious disease, and they gave me a lot of resources. They referred me to a local [HCV expert] doctor. I asked him, “Could it have been related to the surgery?” He said, “Absolutely.”

My greatest fear was that if it happened to me it could happen to other people, because I had no other risk factors. Unbeknownst to me, another patient had been identified with HCV and the investigation had started. We had surgery one day apart in February. It wasn’t until later that the patient letters and notifications went out because that is when an arrest was made. There was about a three-month gap between when I figured out what had happened and the letters went out to patients.

HEH: How did you feel when you were told what had happened?

Lollini: I didn’t know what that term “drug diversion” even meant. I was resigned to the fact that I would probably never know what happened exactly. A phone call came from one of my friends and said, “I think you’re on the news” when the story broke [of Kristen Parker’s arrest]. I can’t tell you I felt relieved by knowing a name and a face. What it did allow me was an opportunity to realize an investigation was done, and that if other people had it, they could be treated.

HEH: You then took legal action?

Lollini: I decided to pursue damages and sue. I told my lawyer, “If I sue, can you promise me that we can make a difference?” Because I did not want this to happen again. If it happened so easily here, it can happen in other places. This was before I really understood the magnitude of drug diversion. The lawyer told me, “I can’t promise we will make a difference, but if you are truly committed to this, I will do everything I can to help you.” I became really outspoken. I wanted people to understand that if it happened to me this easily, it could happen to them.

HEH: It is becoming increasingly clear how widespread and underreported drug diversion is in healthcare. It certainly validates your decision to go public with this.

Lollini: It does, and you know what? I wouldn’t change anything that I did. I don’t work in healthcare, so this idea of drug diversion — that someone could do something intentionally that could harm someone else — was just unbelievable to me. Unfathomable. I had this one isolated incident, and as I continued to speak out there was another, and another, and another. It keeps happening. What are we going to do to stop it? I keep talking to these drug diversion specialists and I think, “If we are all out there together, talking, why is this still happening?” It is still out there.

At least now we have resources we can point to. We have automated systems and we are able to track medications better and able to see errors. There is still the problem of drug-wasting, and reporting waste correctly. There are still problems of hiring diverters who worked at another facility. Up until 2010 in Colorado, surgical techs didn’t even have to register with regulatory agencies in the state. I helped pass legislation for that. There are a lot of things now that are in the works, but not quite there yet.

HEH: You were later called as an expert witness about that law?

Lollini: It’s stranger than fiction. That [2010] bill was in sunset review and I was contacted by some folks who asked if I would support it. I testified via video, but it didn’t look like it was going to be renewed. That’s when the Rocky Allen case happened. Then, of course, not only did the law get renewed, but they were also able to get a couple of amendments added to the legislation. One is mandatory checks, as well as pre-employment drug screenings. I have been able to share my story by joining the folks at IHFDA. These stories are getting out there and are being heard. We are breaking through, finally.

HEH: You have lived with this problem and have been telling your story for quite a while. Is there one action you would like to see taken to address this ongoing problem?

Lollini: I really wish we could have a national registry. Not just for physicians, but for other people in healthcare. So, if someone is considering hiring a Kristen Parker or a Rocky Allen, they can look and see if they were dismissed from another facility. There isn’t something like that in place, so they are jumping from job to job. Even Kristen Parker, once she realized the jig was up and she was going to get fired or let go [at Rose Medical], she actually left and went to work at another medical center in the southern part of Colorado. She left Rose Medical Center in April and was rehired at a surgical center at the end of June. The 4,700 letters that went out from Rose Medical didn’t include the 1,200 letters that had to go out for those other patients.

REFERENCES

1. Brown, J. Hospital tech who spread hep C via drug thefts gets 30 years. Denver Post. February 24, 2010. Updated May 6, 2016. Available at: http://dpo.st/2xxBax4. Accessed Oct. 30, 2017.

2. Osher, CN. Rocky Allen, surgical tech with HIV who stole syringe, sentenced to 6-1/2 years in prison. Denver Post Nov. 7, 2016. Available at: http://dpo.st/2gMnhV1. Accessed Oct. 30, 2017.