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Exeter Patients May Have Suffered Pain from Drug Diversion

Cheryl Clark, for HealthLeaders Media, November 30, 2012

Kacavas acknowledges that it was possible that Exeter's physicians, nurses, or others who worked with Kwiatkowski suspected or knew that their patients were not getting correct dosages of fentanyl, and that they may have observed patients exhibiting symptoms of agitation during their procedures. He also acknowledges that he is investigating whether anyone else at Exeter Hospital knew of a trend or an anomaly indicating that prescription medications had stopped working as they were supposed to and reported it, and what happened to those reports.

"While these charges have been laid against the defendant," Kacavas says, "it is just a point in time in the legal continuum. We are continuing to investigate this case, and there is no individual or no entity that we are excluding as a potential target of our investigation. ...You can draw the inference from that, we're looking at everything."

The U.S. Attorney's Office has interviewed "the large majority of victims in this case," he says, and "although the patients don't have a great recollection of whether or not fentanyl had its intended effect at the time of their procedure, what we're doing is using medical records to show how many micrograms of fentanyl were administered, say, to this particular patient on this particular date."

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1 comments on "Exeter Patients May Have Suffered Pain from Drug Diversion"


Kevin Callahan, CEO, Exeter Hospital (12/4/2012 at 12:11 PM)
Response to HealthLeaders Story: We are aware of no evidence that Exeter Hospital staff knew or suspected that there was a pattern of patients in the cardiac cath lab who were not receiving correct doses of medication. No one reported any "trend" to hospital officials verbally or in writing. Patients metabolize medications such as Fentanyl differently based on a variety of factors, so there is no hard and fast rule as to how much medication an individual should receive. Patients are monitored closely for signs of discomfort and the need for additional medication during every procedure – the objective being to secure patient comfort as best as possible. The investigations that are now underway began as the result of action by Exeter Hospital. Our physician specialists, supported by a sophisticated electronic medical records system, identified a common factor in the hepatitis C cases of several unrelated patients. The hospital voluntarily notified our state health officials, and we removed technician David Kwiatkowski from his position. It now appears that we stopped a tragic pattern that had been underway for years across the country. The national investigation that resulted has uncovered patient victims in multiple states where Kwiatkowski worked, and has reportedly uncovered at least two instances where Kwiatkowski was caught red-handed diverting drugs at other hospitals. Yet key authorities were not informed and credentialing groups did not act. It is reprehensible that this man remained properly credentialed with a clean service record when he arrived on our doorstep in New Hampshire. Exeter Hospital has been cooperating with the federal investigation, and we will continue to do so. But beyond the criminal case against David Kwiatkowski, we believe major changes are needed in the health care industry: 1. There should be mandatory reference disclosure by healthcare providers of problems with former employees that could pose a risk to patient safety. It should no longer be an option to say nothing. Legislators should find a way to protect hospitals that proactively share his information from the threat of employment related lawsuits. 2. As in the case of physicians and nurses who have national registries that track incidents associated with their professional practice, there needs to be a registry system covering all states that can track any healthcare worker who has direct patient care responsibilities and who has evidenced practices that present a risk to patient safety. 3. Hospitals nationwide should review what else can be done in terms of policies and practices to further restrict unauthorized access to medication. We have taken additional steps in this direction at Exeter Hospital that we would be glad to share with other institutions. We are deeply saddened by the impact that David Kwiatkowski's alleged drug diversion had on patients, both at our hospital and at others across the country. We all must work together to ensure this kind of "serial infection" does not happen again. Kevin Callahan CEO, Exeter Hospital Exeter, New Hampshire