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This award-winning blog supplements the articles in Hospital Infection Control & Prevention.

Serratia outbreak may be linked to drug diversion

A former nurse at the University of Wisconsin (UW) Hospital and Clinics in Madison, who allegedly diverted pain medication for personal use, may be linked to a cluster of infections among patients from the units where she worked, UW officials report.

In May 2014 infection-control staff at the hospital noticed a larger-than-average number of patients infected with the bacterium Serratia marcescens, the hospital said in a Dec. 23 statement: “Further investigation showed that in five patients, the infectious agent was genetically identical. One of those patients died.”

S. marcescens is a well established source of health care infections and has caused numerous outbreaks over the years.

In the UW investigation, hospital staff identified that four of the five patients with the genetically identical infection had received pain medication from units where former nurse Stefanie A. Jones worked.

“Later, a connection between Ms. Jones and [a] fifth patient was identified, leading the hospital to contact the police, district attorney, licensing board and other regulatory agencies with their findings,” UW Hospital stated. “All patients or their families have been notified.”

The hospital declined an interview request, but legal documents cited by a Wisconsin newspaper indicate that police took biological samples from the 31-year-old nurse looking for S. marcescens. Jones is accused of diverting morphine and hydromorphone from syringes intended for patients at the hospital more than 40 times between October and March 2014, the newspaper reported. The drugs were replaced with water or saline. In a bizarre twist, one of the patients infected with serratia – the “connection” cited by UW — is Jones’ father.According to police, Nasia Safdar, MD, medical director of infection control at UW Hospital, told police that Jones was likely to have been the host of the serratia, giving it to her father while caring for him. Safdar told investigators it was possible the nurse contaminated the syringes with serratia while refilling them and placing them back into drug dispensing machines.


1. Treleven, E. Warrant: Nurse who stole morphine investigated for patient infection death. Wisconsin State Journal Dec. 25, 2014.