Hospital's Drug Diversion Nightmare Spawns Multiple Infections

Montero says that in some hospitals, human resources departments require random periodic drug testing of employees, although that's not a mandate in New Hampshire.  There are downsides to that, such as fear and morale problems, as well as false positives.

Clearly, this is a problem healthcare leaders need to find ways to solve. In the April edition of the Annals of Internal Medicine, researchers from the Florida Department of Health and the Mayo Clinic in Jacksonville described another case in which five patients were infected with hepatitis C there by a radiology technician, who eventually acknowledged diverting fentanyl intended for patients in the interventional radiology area.

"The technician reported rare self-administration of fentanyl from a syringe that had been filled with fentanyl in preparation for patient care.  The technician would replace the removable needle of the prefilled syringe with a smaller-gauge needle with the original needle, replace the administered fentanyl with saline, and return the filled syringe to patient care."

The researchers concluded that healthcare systems need to implement strategies "to control narcotics in healthcare settings that cannot be circumvented."

While narcotic diversion in the operating room is fairly well understood, the researchers wrote, "relatively little is known about the epidemiology of drug diversion and the effectiveness of strategies to prevent it outside of the operating room environment."

Exeter CEO Callahan acknowledges that the incident has damaged his hospital's reputation, but in a video interview with a local TV station, he tried to reassure the public. Exeter's 2,000 providers, he said, "are doing the very best to instill trust in that care. I cannot believe that one or two criminal actions can so damage the trust of the tens of thousands of people that we've cared for every year."

Montero says that a statewide healthcare quality commission will bring the results of these investigations to all hospitals "so everybody learns from this, and we decrease the probability that it will ever happen again—because it shouldn't."

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