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Hospital's Drug Diversion Nightmare Spawns Multiple Infections

Cheryl Clark, for HealthLeaders Media, June 28, 2012

"You see these patterns of cases that are not clustered together, but are spread out over time, because they're related to when the caregiver brought in that particular syringe."

In Colorado three years ago, a hospital surgical technician was let go after she was found to have replaced fentanyl taken through syringes with saline, sometimes in syringes that had been previously used.  She was only caught after a syringe in the tech's pocket pricked a co-worker. The hospital had to track down 5,700 potential exposures. Before the case was closed, she had re-infected 36 individuals with hepatitis C.

Montero says that the incident "certainly highlights the need for more quality assurance and scrutiny in all facilities. "But at the same time, it highlights how complex the issue of drug use is, and about attitudes we have about drug use in the workplace. And how do we manage that in a society that more and more accepts some drug use at some different levels?"

Hospitals need to incorporate better ways of securing these kinds of medications, Montero says, "so only specific people can have access to them, or you should manage them in specific ways when you are in any procedure room when you are going to dispose of them."

Of course, he adds, all hospitals already do have those policies in place on paper because they have to as a condition of licensure. "But you also must have a procedure to make sure those policies are followed. It's not just what you put on paper," he says.

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1 comments on "Hospital's Drug Diversion Nightmare Spawns Multiple Infections"


Chris (6/9/2013 at 1:35 PM)
Hello, first thank you for taking the time to address this issue. If you have the data, will you please share with me how the Exeter Hospital CaLT actually diverted Rx medications without getting caught prior to the Hep C outbreak? There had to be blood or body fluid transfer into the patients for that strain to enter there bodies. With numbers like 27 confirmed and 17 did not confirm to be of the same strain of Hep C it sure looks like there is missing information from the data. Thus, How would this guy have done what it is claimed he did without a co- conspirater of the accusation simply being wrong?