Infection preventionists should be vigilant in detecting and preventing drug diversion by healthcare workers, as outbreaks linked to this crime appear to be increasing, says Kimberly New, JD, BSN, RN, founder of Diversion Specialists.

“We are seeing a very substantial number of cases of people tampering with injectables,” she says.

“We hear from facilities all the time that they have had a case either recent or in the past of someone who was caught replacing an opioid with saline or something like that.”

Beginning well before the ongoing national opioid epidemic, drug diversion by addicted healthcare workers has caused repeated outbreaks exposing thousands of patients to bloodborne pathogens.¹ These incidents have raised awareness, meaning the increase could in part reflect better case identification and surveillance. Still, some healthcare facilities do not seem to have diversion on their radar.

“I find it very concerning because many times I think that facilities simply aren’t aware of the risk of bloodborne pathogen transmission in these types of cases,” New says.

“So they don’t take precautions that could help protect patients and at least limit the extent of an outbreak.”

As reported² recently by the Centers for Disease Control and Prevention (CDC), the latest outbreak involves an ED nurse in Washington state who admitted to stealing opioids and other drugs intended for patients.

The investigation is ongoing, but the nurse has been linked to hepatitis C virus infections in at least 12 patients who sought care in the ED, the CDC reports.

As with many other diversion outbreaks, the case may have been missed if not for the local health department, which identified two HCV infections in people with no typical risk factors (e.g., IV drug use) in the first few months of 2018.

“The only risk factor was the fact that these patients had been going to this emergency department and receiving injections,” says lead investigator Henry Njuguna, MBChB, MPH, an officer in the CDC Epidemic Intelligence Service. The outbreak could have been missed in part because “not all patients with HCV present with the same symptoms,” he says.

The nurse apparently was originally infected by diverting drugs from a patient with HCV, then infected other patients through contaminated syringes, needles, or vials, the CDC noted.

“This is purely our hypothesis,” he said.

“The nurse told us that she was stockpiling medication for future use. She did not elaborate further as to what she actually did.”

The hypothesis is based on the distribution of infected patients, he explains.

“It is possible that nurse A acquired the virus from [a] patient with chronic HCV infection during [a] Nov. 8 visit and was infectious during Nov. 22–Dec. 26, 2017, during which time at least 12 patients that she treated became infected,” the CDC reports.

The first two patients infected with HCV received treatment from the nurse at the ED on separate visits on Dec. 6 and Dec. 16, 2017.

Upon CDC testing, the HCV infecting both patients was genetically similar, suggesting a common source.

Investigators found the nurse had accessed the automated drug dispensing system much more often than the typical staff. The nurse subsequently tested positive for HCV antibodies.

“This nurse, who had tested anti-HCV–negative and HCV RNA–negative with a blood donation in 2013, admitted diverting injectable narcotic and antihistamine drugs from patients for personal use during current employment at the hospital ED, though she did not specify the mechanism,” the CDC found.

The investigation is continuing, with some 90 additional patients being contacted and recommended for bloodborne pathogen testing. State nursing officials suspended the nurse’s license to practice.

New was not involved in investigating the case, but she commented about IPs and drug diversion in the following interview, which has been edited for length and clarity.

HIC: Should IPs be more proactive and get involved in this issue?

New: Absolutely. In fact, I am speaking at a number of regional APIC [Association for Professionals in Infection Control and Epidemiology] conferences this year. There is increasing awareness among infection preventionists of what their role should be in these type of cases because historically they have been excluded. My recommendation is that they need to insert themselves into the diversion program. If there is one at their facility, they need to make sure that they are an active part of that. It may require them presenting to the committee the risks, and getting people to understand why their role is so important.

HIC: This recently reported outbreak certainly shows it is an ongoing problem.

New: Healthcare facilities really need to take any kind of drug diversion seriously, and always — in every single case — consider the risk that there has been tampering and substitution. Across the country, in my experience, sometimes infection preventionists have a hard time selling that we need to really look at this. It potentially can expose healthcare facilities to a fair amount of liability. It is something that every single facility needs to consider at the beginning, when they realize that they have had injectable diversion.

HIC: This problem historically has been driven underground by hospitals concerned about liability following patient notifications. Do you see that changing now?

New: A lot of facilities now are promoting being more open about medical errors. Trying to promote that type of approach obviously would be a better way to handle these. I think the potential for harm to patients is so significant, it is not something we can ignore. For example, Stanford developed an approach to medical errors where they are very candid and open with patients about problems that occurred and that they may not otherwise be aware of. They feel that the candid approach has decreased their litigation from patients in the long run. [Drug diversion] should be approached in a similar fashion. Instead of being overly concerned about liability, really look at the risks to patient harm at the front end and err on the side of caution.

HIC: This hospital apparently had some drug diversion oversight and saw that the nurse was taking out more medications than her colleagues. Unfortunately, that was after the patients were infected.

New: I am not speaking to this facility, but in general, a lot of facilities still do not have a formal drug diversion program where they have someone who is ensuring there is ongoing effective auditing and making sure that anomalies in drug cabinet transactions are followed up on. That type of auditing and work is very labor-intensive. In most facilities, it really does warrant having a full-time person in charge of that. I think the cases like this are making that more common.

HIC: More facilities are adopting formal drug diversion programs?

New: We have seen a huge number of facilities that have begun to put a diversion program manager in place and really have turned to approaching diversion with a more formal program, policies, committees, and oversight.

I think this type of case underscores the need to have someone who is looking at that data, an objective person who has this assignment and accountability. Many times, a facility does not have dedicated resources. Pharmacy may look at these reports and they send them off to clinical leaders who will try to look at the reports when they have time. It is a disjointed effort, and we have people who have full-time jobs trying to add in some auditing. That is a setup for missing something.

HIC: Realizing you were not involved in this investigation, do you have a theory on the type of diversion that may have led to the outbreak in Washington?

New: We see a number of different things in these types of cases. We see individuals who go into the PIXIS [machine], take out these syringes, inject themselves, fill them up with something else, and then put them back. In that way, she could have transmitted bloodborne pathogens because there are tampered syringes — filled with something other than the opioid — now tinged with her blood.

Another way we see them doing this is that they draw up the contents of a vial, give themselves half of it, and then fill the [syringe] back up with something like injectable diphenhydramine. It makes the patient feel like they have gotten something by having a sedation effect. They are diluting what the patient is given, but they are using the same needle. People who are doing this are desperate. They are not paying attention to what they have been taught as a healthcare provider in terms of safe injection practices.

REFERENCES

1. Schaefer MK, Perz J.F. Outbreaks of infections associated with drug diversion by US health care personnel. Mayo Clin Proc 2014;89:878–887.
2. Njuguna HN, Stinson D, Montgomery P, et al. Hepatitis C Virus Potentially Transmitted by Opioid Drug Diversion from a Nurse — Washington, August 2017–March 2018. MMWR 2019;68(16):374-376.