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'Serial Infector' Investigation Points to Need for Federal Registry

Cheryl Clark, for HealthLeaders Media, August 2, 2012

30 patients infected

By the time authorities caught up with him this spring, Kwiatkowski, 32, had allegedly infected 30 patients with his strain of hepatitis C virus, and "recklessly put patients at risk of death or serious bodily injury," according to the affidavit.

Now, many of those 11 other hospitals that employed him from 2007 on—from Wayne, MI and Poughkeepsie, NY to Johns Hopkins Hospital in Baltimore—are digging in their files to see if they have negative drug screen tests for Kwiatkowski during his employment. Some say they are in the clear. But many others are busy searching for former patients to bring them back for testing.

Kwiatkowski and his checkerboard career managed to elude human resources departments, despite the fact he was reportedly fired from Arizona Heart Hospital in Phoenix after being found unconscious in the men's bathroom next to a toilet containing a syringe labeled fentanyl.  Admitted for care, he tested positive for cocaine and marijuana.

He reportedly relinquished his license and Arizona officials stopped their investigation. The staffing agency that had placed him reported him to the American Registry of Radiologic Technologists, the professional organization that credentialed him. But the registry reportedly said no criminal charges had been filed and that he passed a drug screen. Besides, the registry reportedly said, it "did not have firsthand evidence."

So Kwiatkowski  moved on to Temple University Hospital in Philadelphia. Then to Hays Medical Center in Kansas, which is trying to find 460 patients with whom he may have had contact. Then he went to Houston Medical Center in Warner Robins, GA, which is also trying to notify patients that might have been exposed.

Kwiatkowski was in Pennsylvania previously during 2008 as a technician at UPMC in Pittsburgh. He was fired  there, too, after he was seen in an unauthorized area.

Montero says he must choose words carefully because the case is still under investigation.  But it's clear the matter keeps him awake at night.

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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.