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'Serial Infector' Investigation Points to Need for Federal Registry

Cheryl Clark, for HealthLeaders Media, August 2, 2012

Drug addicts are patients, too

Montero points out that another vexing issue is that drug addiction itself is a disease and those who suffer from it are patients, too. "You try to reach a balance between helping someone with a disease and protecting the public. It's extremely tricky, and I'm not sure I have the answer.

"When something like this goes on your record, it never goes away, and people will think you're a drug user all your life. People do make mistakes, but how much should we accept or tolerate?"

Maybe, he says, if such incidents are always reported to a registry as he suggests under a strong national policy, a person could return to work "if they can prove they had treatment and are no longer users."

Not the first case

Clearly better policies are needed because similar cases have popped up around the country. In Colorado, a 26-year old surgical technician injected herself with fentanyl three years ago, and then replaced it with saline for reuse in patients. At least 36 patients were infected with hepatitis C, and hospitals had to find 5,700 patients with whom she could have exposed.

Several weeks ago I asked Montero if he thought Exeter Hospital's small, 100-bed size and rural setting led to the discovery of the problem that eluded those in more urban settings. He didn't think so.

But this week, he's changed his thinking. "In New Hampshire we were able to stop this national problem because of the confluence of several things. First, we had a clinician who thought about it when he saw these infected patients with no risk factors whatsoever. And second, we (the health department) had a good relationship with the hospital and were immediately notified."

At a bigger hospital in a bigger state, patients may not be seen by the same providers, so no one draws the link, "no one talks to each other," Montero says. That's a scary thought.

Montero hopes that the painful episode may teach the nation's hospitals and policymakers an important lesson.

"There's a need for systemic improvements, not just a patchy remedy that we do state-by-state and hospital-by-hospital," he says. "Healthcare is a system and we need to work with it as a system."

"But there I go on the soapbox, preaching again."


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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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.