Hospital's Drug Diversion Nightmare Spawns Multiple Infections

"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.