Hospitals and other healthcare organizations need to do a lot more than what they're currently doing to guard against drug diverters and catch them before they harm patients and themselves.
Federal health officials have sounded an alarm this week about a group of healthcare workers who are surely harming patients somewhere this very minute, engaging in behaviors about which most hospital officials are unaware or choose to ignore.
These are drug-addicted healthcare workers who divert injectable drugs and, in the process, contaminate the syringe and infect patients for whom the drugs were intended, depriving the sick of the sedation they require.
The problem is huge, it's growing, it's often swept under the rug or ignored, and we only know about the tip of the iceberg.
That's the scary warning from Melissa Schaefer, MD, medical officer, and Joe Perz, prevention team leader, for the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention.
In an hour-long conversation this week, Perz told me that hospitals and other healthcare organizations need to do a lot more to guard against drug diverters to catch them before they harm patients and themselves. But so far there just hasn't been much interest.
"The tendency has been first of all, to not look for a problem. And then, when a problem presents itself, a common approach is to deal with it as discreetly as possible. Unfortunately that ignores the laws and regulations that require prompt reporting of diversion…We have to overcome this idea that it's somehow optional because it's not optional to report when theft or a loss of a controlled substance is identified."
A Bigger Problem Than Perceived
In a paper published Monday in Mayo Clinic Proceedings, Schaefer and Perz report findings from their extensive review of CDC records, including unpublished reports, to crunch some numbers. They've concluded that healthcare worker "tampering" with patients' medications has resulted in 118 patients infected in the last 10 years in six episodes, more than expected.
Of those six incidents, four have occurred since 2008, affecting 84 patients and indicating a mushrooming problem. For the healthcare facilities involved, the workload was enormous and devastating to institutional reputations. In total, some 30,000 patients put at risk by the four most recent incidents had to be contacted for testing, and had to deal with the emotional and practical repercussions of possible exposure to infection.
Perhaps best known is the nightmare of David Kwiatkowski, a traveling catheterization lab technician now serving a 39-year prison term. He was convicted in December, 2013 of stealing the drug fentanyl from syringes he first used on himself. His theft and disregard for patients transmitted his hepatitis C infection to some 45 unsuspecting patients undergoing procedures, including one who died.
Kwiatkowski, had worked in as many as 12 hospitals in eight states, though suspicious behavior prior to his capture went unreported. Finally in 2012, a cluster of infections at a single, small facility led investigators to his employment at the 100-bed Exeter Hospital in New Hampshire.
This week, to announce its call for more awareness and hospital-based drug diversion prevention programs, the CDC launched a website devoted to the topic of healthcare worker drug diversion. It explains that theft of a controlled substance by a drug diverter can result in:
- Substandard care delivered by an impaired provider,
- Denial of essential pain medication or therapy, and
- Risks of infection with hepatitis or bacterial pathogens.
As Serious as an SSI
Perz believes hospitals should start thinking of drug diversion as an adverse event as serious and common as a surgical site infection, The rate for those approaches 1% in some hospitals and drug diversion is likely just as common, he says.
The 118 incidents he and Schaefer reviewed, he says, are "clearly an underestimate of the true burden of patient harm that results from healthcare workers stealing controlled substances and tampering with opioids and other drugs. It struck Dr. Schaefer and me that awareness and appreciation of this issue and its magnitude are lacking."
Perz points to estimates from the federal Substance Abuse and Mental Health Administration showing that more than 100,000 employed healthcare workers have substance abuse issues. And he references a survey of anesthesiologists in training last year that found 1% were caught or died from their addictions.
Happening Everywhere Controlled Substances Are Used
Kim New, who until recently was hospital manager of controlled substance surveillance at the University of Tennessee Medical Center, tells me that in that role, she apprehended—through diligent tracking—one or two addicted nurses per month for diverting drugs from patients.
"I think diversion of controlled substance medications intended for patients occurs at absolutely every institution that handles controlled substances —every nursing home, physician practice, and hospital, and it's something that will happen at every institution regardless of what prevention efforts you put into place. It's gone too far," says New, now a drug diversion consultant and blogger for the CDC's new website.
The best thing a healthcare facility can do, to the extent they are capable, she says, is to "identify it quickly and respond appropriately."
But hospitals have many reasons and incentives to look the other way. In talking with experts, I counted at least six:
Plausible Deniability
- The time between the patient's exposure to the drug diverter's theft and appearance of symptoms and diagnosis may be years.
- Linking the patient's infection back to the drug diverting healthcare worker requires genetic analysis that may require sophisticated and costly testing.
- If symptoms of infection do appear relatively soon after the patient is discharged, they may be written off as stemming from the patient's original medical condition that drew them to the hospital for care. Some patients die.
- Reporting to law enforcement and public health or state licensing agencies means assignment of hospital personnel and resources to conduct investigations of staff workers, which may lead to morale problems, especially for smaller hospitals.
- Negative publicity could cripple a hospital.
- Reporting can expose a hospital to lawsuits from patients even if they weren't infected but merely exposed. Recent litigation has resulted in financial findings against hospitals accused of improper infection control and drug administration practices.
There are more, but the point is this: The weight needs to shift so it's riskier to ignore the problem than to fight it.
Hospital Financial Survival at Stake
In an accompanying editorial in the same issue of the Mayo Clinic Proceedings, two anesthesiologists called the Perz and Schaefer paper "frightening," as they expanded on the financial ramifications for each hospital where such an incident took place.
"When taken in aggregate, these experiences hint at the magnitude of potential hazards that disease transmission by drug diverters…creates for not only the patients but also the financial survival of the healthcare facility," wrote Mayo Clinic anesthesiologists Keith H. Berge, MD and William L. Lanier, MD.
"The sum of awards against a given entity can potentially be an immense sum of money."
And because every facility that handles divertible drugs "is at risk for an unscrupulous HCW not only diverting drugs but doing so in a manner that could harm patients and others, then the question becomes not 'How can we afford a program to prevent and detect drug diversion by HCW's?' but instead 'How can we afford to not have such a program.' "
The answer is obvious.