How much harm can a single drug diversion actually cause your facility? All it takes is one stolen or tampered syringe to cause a potential outbreak. Without a watchful eye, entire health care facilities are at risk of exposure.
For example, one diverting surgical technician put 5,900 patients at risk due to their carelessness. Not only did they expose patients to the disease, they also used fentanyl syringes for self-use. It led to 19 confirmed cases of Hepatitis C, and the diverting surgical technician now faces 30 years in prison.
In a separate outbreak instance, another surgical technician potentially exposed 2,900 patients to Hepatitis B, Hepatitis C, and even HIV infection. 2 people tested positive for hepatitis as a result. This surgical technician faces charges of tampering and obtaining fentanyl by deceit.
Lesson learned: all it takes is one irresponsible surgical technician to cause a scare or outbreak. Patient safety is of the utmost importance — keep a watchful eye on any syringes in use. All it takes is one surgical technician to steal a syringe to compromise an entire facility. Check out the infographic below from Diversion Central by Omnicell for more information.
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
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.
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