These days, we see drug diversion incidents appear in the news at an increasing rate. 28,000+ patients were potentially exposed to Hepatitis C Virus (HCV) through drug diversion. All of this was due to the carelessness of HCV-infected health care providers.
While its tempting to dismiss as a rare happening, this high exposure rate can happen anytime without proper precautions. For example, one surgical technician caused 18 cases of HCV infection with more than 8000 total patients impacted across three facilities. This single event resulted in a 30-year prison sentence for the diverter.
Although these numbers are staggering, it is easy to lose sight of the fact that these numbers represent real people. These people’s lives were devastated because a healthcare provider tampered with needles, syringes or medication vials to get ‘high’. These people could have been your child, your spouse, your mother. If you access healthcare, it could happen to you. The irony is that these people acessed healthcare seeking better health, but in the process, were exposed to a deadlly disease. And the situation is completely preventable with procedures and policies in place that are designed to prevent drug diversion.
Drug diversions can spread more than HCV. Other infections diseases associated with drug diversion include: pseudomonas pickettii, serratia marcescens, achromobacter xylosoxidans, ochrobactrum anthropi, stenotrophomonas maltophilia, and klebsiella oxytoca. It’s imperative to educate yourself on these diseases and how they can spread from drug diversion.
Patient safety is of the utmost importance, so arm yourself with knowledge of how to prevent, address, and handle drug diversions. Ensure all of your syringes and saline solution are not compromised or tampered with. Check out the infographic below from Diversion Central by Omnicell for more information.
Medical Xpress, a publication of the Society for Healthcare Epidemiology of America, recently reported a cluster outbreak of Serratia marcescens, a gram-negative bacteria, due to drug diversion through tampering of syringes
The enlightening article describes how drug diversion through syringe tampering happens, its ramifications (including loss of life), and efforts to prevent it.
Drug diversion by healthcare workers is a growing problem in the United States. We must learn from outbreaks such as this if we hope to prevent others from happening.
The article is reprinted here in its entirety.
Narcotics diversion results in outbreak of serratia marcescens bacteria
July 6, 2017 in Medicine & Health / Diseases, Conditions, Syndromes
An illegal diversion of opioids by a hospital nurse tampering with syringes was responsible for a cluster outbreak of Serratia marcescens, a gram-negative bacteria, according to research published online today in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America. Five patients admitted to five different hospital wards within University Hospital in Madison, Wisconsin developed identical bacteria strains. Upon investigation, hospital epidemiologists linked the cases with the tampered syringes, the nurse was immediately terminated, and no further S. marcescens cases were identified.
“This incident sadly adds to the handful of healthcare-associated bacterial outbreaks related to drug diversion by a healthcare professional,” said Nasia Safdar, MD, PhD, senior author and hospital epidemiologist at the University Hospital in Madison, Wisconsin. “Our experience highlights the importance of active monitoring systems to prevent hospital-related drug diversion, and to consider this potential mechanism of infection when investigating healthcare-associated outbreaks related to gram-negative bacteria.”
Hospital staff first identified four hydromorphone and six morphine syringes in an automated medication dispensing cabinet that had been tampered with. This discovery occurred almost immediately after detection of the S. marcescensoutbreak, prompting a controlled substance diversion investigation (CSDI) by key hospital staff.
Hospital epidemiologists conducted a review of blood cultures and molecular fingerprinting to identify the origin of the S. marcescens outbreak, concluding the possible connection between the cluster of infections and the narcotic diversion. Further analysis suggested four of the five exposed patients had contracted S. marcescens during a short-term post-operative stay in the Post-Anesthesia Care Unit, where the nurse worked. The fifth patient, who was the nurse’s father, had been exposed to the bacteria prior to his admittance.
The investigation found that the suspected nurse had accessed the medication cabinets where the tampered medication was stored. Testing of the tampered syringes suggested the nurse had replaced the active medication within the syringes with a saline or other solution, likely causing the S. marcescens outbreak. Four of the five patients recovered, while one died from Serratia sepsis infection.
As a result of the outbreak, the hospital team implemented additional diversion detection and security enhancements including tamper-evident packaging and installation of security cameras.
More information: Leah M. Schuppener et al, Serratia marcescens Bacteremia: Nosocomial Cluster Following Narcotic Diversion, Infection Control & Hospital Epidemiology (2017). DOI: 10.1017/ice.2017.137
Provided by Society for Healthcare Epidemiology of America
What are the next steps when your facility is ready to make a change because they are committed to patient safety? How does a facility educate their staff in the reasons for and the process of performing random drug screens on all who have access to controlled substances? What do they do when many staff threaten to quit if random drug screens are implemented? Below are some suggestions.
Excerpts taken from “Cuyuna Regional Medical Center’s Drug/Alcohol Free Workplace and Testing Policy”
Why do it (Goals):
<Facility Name> is committed to providing high quality health care services and acknowledges the importance of each employee to the effective function of a competent health care team
<Facility Name> sees substance abuse as a very serious problem and as a threat to employees, volunteers, patients and visitors
The ultimate goal of this policy is to balance our respect for individual privacy with our need to maintain a safe, productive, drug/alcohol free work environment
<Facility Name> is committed to maintaining a work environment free from the influence of alcohol and/or drugs and thereby protecting the health, safety and well-being of patients, employees, volunteers and visitors
<Facility Name> employees are required to immediately notify their supervisor if any member of the health care team is not in appropriate mental and/or physical condition to safely perform their duties. They should not be allowed to perform any duties
Assuming a reasonable suspicion, the employee will be escorted to the laboratory department for testing
An individual who refuses to be tested, or whose behavior prevents completion of the testing, such as – tampering with the sample or testing materials, behavior intended to provide a dilute sample, failure to provide specimen within a reasonable amount of time (3 hours from initiation of testing) or not providing the required amount (30 cc) – will be subject to termination, other disciplinary actions, or have the employment offer revoked
An individual has the right to refuse testing, but they must be made aware that such refusal may result in disciplinary action including termination
For the individual’s safety, arrangements may be made for:
Transportation: the individual will be sent home with a sober adult
If he/she insists on driving home, city law enforcement will be notified.
The individual will remain off work on paid leave until all drug testing results are received and confirmed
<Facility Name> will instruct employees on the common identifying factors of drug use and diversion, some of which are:
A nurse uses the maximum PRN dosage when other nurses use less
A nurse insists on personal administration of injected narcotics to patients
Statements such as…“If anybody needs help passing their pain meds today let me know.”
A patient states that pain medication was not given but documentation shows that it has been administered
A nurse shows frequent wastage of drugs for “spillage”
Sloppy or poor record-keeping
A nurse’s handwriting or charting deteriorates
Increased absenteeism is common in end-stage addiction
Increased disappearances from the work-site or increased taking of breaks
Increased/frequent or long trips to the bathroom
A nurse will often appear at work when not scheduled
Deterioration of interpersonal relationships with colleagues, staff and patients
Will not admit errors or accepts blame for mistakes or oversights
Personality change: mood swings, anxiety, depression, lack of impulse control
Patient and/or staff complaints about health care provider’s attitude and behavior
Many will be angry over the facility’s decision to begin random drug screens of employees with access to controlled substances. They will cry out that it is unfair; it is an invasion of their privacy; it is costly; they may even threaten to quit and some actually will quit. Let them rant, but continue to remind them that you are committed to patient and employee safety. Your goal is to minimize, even eliminate, drug diversion at your facility and this is one of the best ways to do that.
It is important to remember that the policy is being done to maximize patient and healthcare worker safety, not to punish. The policy is not to invade anyone’s privacy. Unfortunately these days, we have to be vigilant in our quest to stop drug diversion, it is pervasive and it is getting worse. Just do a Google search for drug diversion in healthcare and you’ll see so many examples of the problems that accompany diversion. There is something we can do, we can simply drug test those with access to the drugs that are most commonly diverted. We can test the syringes that are returned as waste. We can let addicts know that we are watching them and we will discover what they are doing. Most importantly, we will get them help.
Today I would like to share a bit about the Florida Board of Nursing’s “Intervention Project for Nurses” or IPN. It is similar to other Drug Diversion Programs that many states have, but it has a piece to it that is a bit different…they have a statewide support groups for nurses. This interests me, what a great idea. To have nurses that have been through the same issues regarding drug diversion talk to those who are beginning their journey is a very valuable tool.
“The mission of IPN is to ensure public health and safety by providing an avenue for swift intervention/close monitoring and advocacy of nurses whose practice may be impaired due to the use, misuse, or abuse of alcohol or drugs, or a mental and/or physical condition. IPN is authorized by Florida Statute, Chapter 464/456, to assist those nurses whose practice is affected.”
To ensure public health and safety through a program that provides close monitoring of nurses who are unsafe to practice, due to the use of drugs including alcohol and/or psychiatric, psychological or a physical condition (chapter 455.261).
To provide a program for affected nurses to be rehabilitated in a therapeutic, non-punitive, and confidential process.
To provide an opportunity for retention of nurses within the nursing profession
To facilitate early intervention, thereby decreasing the time between the nurse’s acknowledgment of the problem and his/her entry into a recovery program.
To require the nurse to withdraw from practice immediately, and until such time that the IPN is assured that he/she is able to safely return to the practice of nursing.
To provide a cost effective alternative to the traditional disciplinary process.
To develop a statewide resource network for referring nurses to appropriate services.
To provide confidential consultations for Nurse Managers.”
The IPN has a vast network of resources for nurses. Florida has 150 Nurse Support Groups throughout the state. Each group has a facilitator. This is what one had to say, “I have been a Nurse Support Group Facilitator for over 12 years. I have witnessed many nurses come and go from my groups. The “magic” of the Nurse Support Group lies in the fact that a nurse who feels totally alone and full of negative self-talk and shame, secondary to his or her substance use disorder, attends group with other colleagues who have struggled with similar feelings and circumstances. There is a realization that “I am not alone anymore” and hope is born.” And one of the participants shared this, “Walking into my Nurse Support Group the first time surprised me. I will never forget the experience. My first surprise was how welcoming folks were to me. I listened as members shared a little about themselves with me, and I was amazed how similar the stories were to mine! I left that night with a sense of hope.”
I know when I first started this journey, I needed to speak to other people going through what I was. I was lucky in the sense that my counselor had another nurse she was treating with almost the exact same issues. What I didn’t have was someone who had been successful in going through the BON’s program and returning to practice. It would have been very helpful to have someone walk me through the process. As it was, I fumbled around with a lot of anxiety and some missteps. I would love to be a resource for nurses new to the BON monitoring program and new to sobriety. 12 step programs are essential in my opinion and they have worked so well for me, but they do not include anything about how to recover as a nurse. Including how to navigate the overwhelming program requirements, how to deal with the feelings of shame and remorse, how to get to a point where working as a nurse is a possibility again. I could be that resource, there are many like me that could. Together we can make a difference.
Kristin has been a Registered Nurse since 1991. After losing so much to alcohol and drug addiction, she turned her life around and has been sober for more than 11 years. Kristin now works in the clinical research industry, has published a book about her story of addiction and recovery, and works with others who face those same struggles. Her blog focuses on the reality and pervasiveness of the problem (especially in healthcare) and offers real solutions to those who are ready to hear them. She regularly posts a blog about drug diversion among healthcare providers. Her post from April 3, 2016 is shown here. You can also access Kristin’s blog here.
Last month I heard about a young nurse, age 23, who died of a heroin overdose. Jessica was dropped off at an ER in a comatose state by an unknown man. There were track marks on her body. Her family was stunned, they had no idea she used drugs. She was a nurse at a local hospital; she was studying to become a registered nurse. Her family said there were no signs that indicated she had a drug problem…no signs. That is the key point in this story to me. Nobody knew I was using either. We addicts can be so good at hiding our drug use. This is why we need to be randomly drug tested. Maybe if they had this requirement at the hospital where Jessica worked they would have caught her. Sure, it would have been devastating to this young nurse. Her career dreams would have been seriously altered. But she would have been alive. She would have had the opportunity to start her life, her career over again. She may have been successful at fighting her addiction, she may not have been, but she would have had a chance. She has no chance now. It is such a waste of a life, what could have been a beautiful life.
I used drugs for years and nobody knew – nobody. I was smart, or so I thought. I knew how much I could take while working so that nobody would suspect. Please note that I write ‘while working’. I did not just do this in the privacy of my home while my children were safely tucked in bed. No, I did it whenever I could. While working, while driving, while taking care of my kids, while visiting friends and family, anytime I had drugs to take. As my addiction progressed I became less able to control when and where I used them.
Yet I was one of the lucky ones, although it didn’t feel that way at the time. I got caught before having to suffer Jessica’s fate. Nobody suspected I was using until the stock supply started disappearing. You see, after a time I could no longer wait for the ‘waste’ drugs, I craved them so badly. Once I started taking the stock supply it didn’t take them long to figure out it was me. I was arrested and charged with 26 felonies. I was absolutely devastated. I had no idea what I was going to do. But again I say, I was one of the lucky ones; I ended up getting clean (after a few more stumbles) and have stayed that way for 11 years (and counting). I am a nurse in good standing again.
I think the most important thing to take away from this blog is that you can’t always tell if someone is using drugs or not using drugs. If you depend on being able to identify those with a substance abuse problem by sight you will be missing many of them. Sure there are some that reek of alcohol, pass out in bathrooms or get arrested, those are the obvious cases, but there are just as many that are hiding an addiction that nobody can see. They are the ones that we need to focus our attention on. They are the ones that may be helped if random urine drug screens would be required of all healthcare workers with access to controlled substances. Detecting their problem could prevent a death. The death of the addict or their patient’s death. They are dangerous, I was dangerous. I didn’t think so at the time, I thought I had it all figured out. But I was fooling myself. Anyone who is high at work is risking their patient’s safety. Their decisions and reactions are flawed.
Please join me in my quest to get people to listen. The public needs to understand the scope of the problem. The Licensing Boards need to advocate for random drug testing. The government needs to require it. I am one voice and few are listening to me. I need more voices.
In this piece, spurred on by the maelstrom of events which surrounded the arrest of a surgical tech from Swedish Medical Center the previous month, Osher and Olinger point out the simple truth that hospitals do not all prescribe to the same standard of safety and precaution when a drug diversion occurs. It was made clear that simply not reporting a theft, leaves open the possibility of hiring of these drug diverting healthcare workers at other facilities and allow them to continue their diverting ways. These reporters did an extensive job in reviewing state health department, licensing board and police records. And the results were unbelievable. Read more
With all the recent drug diversion incidents swirling around, we thought we would feature a guest blogger, Kristin Labott-Waite, to share opinions on healthcare workers and addiction. This is a re-print from her blog posted January 2, 2016.
As I sit here today with my good friend Butch and his daughter Paige, I am reminded that life is very short. Paige has melanoma in her brain and it has been progressing in recent weeks. We do not know what to expect next and that is the scariest thing. While I sit here I am contemplating why things happen the way they do. Why, after all the shit I pulled am I healthy and strong, and 22 year old Paige is so sick. Paige has a 16 month old daughter to take care of too. It isn’t fair. She is on all kinds of pain medication, fentanyl patches, Dilaudid, morphine, meds she needs to keep the headaches at bay. I know that she is using those meds because she needs them. While we sit here at the hospital I worry about people stealing the meds she so desperately needs. Read more
Over the past few months, the news has been riddled with stories of a surgical tech who diverted drugs in 4 states. He was finally caught in Colorado when a fellow employee finally turned him in. But the question remains, how did he go from a Navy court martial to wreaking havoc across multiple states and several hospitals?
We hear more about drug diversion, especially over the last decade, because we are catching more diverters. Kim New, executive director of the International Health Facility Diversion Association, states that “diversion almost certainly occurs at every institution that handles controlled substances, and the rate of discovery of diversion events has increased steadily over the past decade. “ And while most facilities have certain protocols in place, there is no formal set of rules to govern all, so there remains lots of gray areas which allow employees to slip through the cracks. Read more
News broke a few weeks ago about a possible drug diversion event in Colorado. The more we here about the details of this incident, the more we understand just why a national registry for healthcare workers is so important. Even with the current registry the state of Colorado has for surgical technologists, we see that we have still fallen short in regard to gaps in the system.
It appears the surgical tech who was caught with a syringe in an operating room where he was not scheduled has lost every previous hospital job due to drug violations. At least one other job he was caught stealing a syringe and in still another he tested positive for fetanyl. It appears 4 states are now involved in an ongoing investigation. Read more
This past week we learned that there was another incident of drug diversion at Swedish Medical Center in Englewood, Colorado. This is not far from Rose Medical Center in Denver, the site of the 2009 drug diversion event which caused 19 patients to be infected with Hepatitis C. So if this seems eerily familiar, you are right, it is.
At last report, no exposure to any infectious diseases have been reported. My sincere hope is this remains to be the truth for the almost 3000 patients who were notified that they may have been put at risk.
But the cold hard facts remain. There was another drug diversion at an HCA hospital, the same hospital system which includes Rose Medical Center. And I am sure the most asked question is going to be “Why?” Why were there not better systems put into place to safeguard again this? Why did we not learn from the mistakes made in 2009?
We ask why because we know this was a completely preventable event. We ask why because despite any reliable data about the frequency of drug diversion in healthcare facilities, primarily due to the covert nature of this crime, we know it is always a possibility, always a risk. We ask why because there are many hospital systems who have successfully been able to monitor, assess and prevent drug diversion incidents.
So while my thoughts remain with those 3000 patients and their families and friends as they await news of their blood tests, I find comfort in knowing behind the scenes the Colorado Department of Public Health and Environment is doing what needs to be done to investigate, educate and keep the risks at a minimum. With the help of the CDPHE’s One and Only Campaign, awareness is being raised among patients and healthcare providers regarding safe injection practices. Or if more information is needed, please contact HONOReform at www.honoreform.org.
Below you will find a guest commentary which appeared in the Denver Post this past Saturday offering solutions for the future.