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'Serial Infector' Investigation Points to Need for Federal Registry

Cheryl Clark, for HealthLeaders Media, August 2, 2012

A national problem

"This is a huge issue for the nation," says Jose Montero, MD, director of the New Hampshire Division of Public HealthServices who leads his agency's investigation of Exeter Hospital, where Kwiatkowski worked for more than a year. Montero has been looking into the mess for three months so far, and officials from the Centers for Medicare & Medicaid Services and several other federal agencies are investigating as well.

That there is no national requirement that all hospitals and states must report such individuals makes Montero so angry, he pauses the interview to apologize, "for getting on a soapbox."  Instead of a uniform registry, there's a patchwork of state-by-state autonomy, he says.

"Each state has the capability to determine a lot of things that impact the population of that state," he continues.  "But we are missing the point.  Having different requirements for licensing in different states is too haphazard.

"When you look at the affidavits and the criminal information that has been disclosed out there, and how he was able to move from state to state...this just shouldn't have happened."

On July 19, the New Hampshire U.S. Attorney's Office charged Kwiatkowski with fraud and drug diversion related to the theft of syringes filled with the anesthesia drug fentanyl intended for cardiac catheterization patients and injecting them in himself. According to the indictment, Kwiatkowski would then replace "the drug in the syringe with another liquid (such as saline), which is then injected into the patient."

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1 comments on "'Serial Infector' Investigation Points to Need for Federal Registry"


Karen Jensen RN,BSN,CCM (8/6/2012 at 8:23 AM)
I would like to say that as a nurse in a supervisory role for many years that I have reported people to the Board of Nursing in the state where I live and they have done nothing. They always send a letter stating that their investigation did not yield any wrong doing and they don't stop these people from working. What we need is for the Board to take ACTION when they hear a complaint from a licensed person and they need to make the person be pulled out of the workforce until a result has been determined whether injury occurred to a patient or that person is drug addicted and needs to join the board peer assistance program and not return to work until they have completed a full rehab program. This guy is a type of serial killer which the CNN report described him as and you cannot stop every serial killer but you can report to the board immediately any concern and let the board use their power to make the individual stop work until they are cleared. This will prevent it from going from state to state. So we need savvy and intelligent people who work for the nursing boards or registries for ancillary health professionals to pull these people out of commission at the first firing for bizarre conduct and not waiting until 5,000 patient's are infected. The Board has to act immediately in order for this to work and in my experience the board is slow and will tell you it takes up to a year to investigate. By that time, who knows how many people will be injured. The board did nothing when two patient's expired from nursing errors and I reported 2 LVN's and a nurse practitioner and they did nothing. They said that just knowing that they might have done something wrong is enough to make them improve their practice. It was a ridiculous response. I was the acting DON at the time.