Back in the summer of 2012 news reports invaded my inbox regarding the Hepatitis C outbreak discovered in Exeter, NH. My friends and colleagues in the patient safety world were concerned. How could this happen again, they asked. I recall my own sadness at hearing the news, understanding all too well what those victims, their families and the community might be feeling. This incident was so similar to the one we experienced in 2009 in Denver, CO.

My heart broke a little more just this past week when David Kwiatkowski, the medical tech who was responsible for infecting 46 patients with Hepatitis C as he diverted syringes of fetanyl for his own use and reused those same syringes, filled with saline, on patients. The infectious disease he carried had spread to 46 innocent people. When all was said and done, it was reported that Kwiatkowski had worked in 7 different states, putting so many patients under his care at risk. One patient died and health officials have stated her death was directly related to her acquiring Hepatitis C from David Kwiatkowski.

39 years was the final sentence handed down on December 2, 2013. Kwiatkowski expressed remorse. But for the victims and their families, several who were able to speak out the day of sentencing, it was simply not enough. The damage had been done. Dozens of people now live with the ravaging effects of Hepatitis C. I think of pain medication which should have been received by patients, yet wasn’t. I think of the physical toll, the lengthy treatments and the loss of life. I think of the way lives have been altered, irreparably, because a technician was able to divert syringes for his own addictive needs.

And I ask, why does this continue to happen? Why can we not learn from past mistakes? Drug diversion is not an urban myth, as some might have you believe. It is an epidemic with deadly results.

First, hospitals and health care facilities must take a look at their internal protocols and review their systems and ensure they are enough to keep patients safe. But more importantly, they have to assess if these systems are even being utilized. This is only the beginning.

The state needs to bring in patient centered laws which tighten requirements and ensure compliance. New Hampshire is leading the way. Representative Tom Sherman is backing the medical technician registry bill, which will require techs of all kinds in New Hampshire to register—same as physicians and nurses. HONOReform representatives will join Rep. Sherman and colleagues at the New Hampshire statehouse in January to push to have this essential bill signed in to law.

And finally, we need to look at a national registry, a better way of communicating from state to state to report drug diversion. We need a systemized approach to more quickly identify situations which arise when an employee jumps from facility to facility as Kwiatkowski did. We know drug diversions happen. We know outbreaks happen. Let’s get in front of the problem and be proactive instead of waiting until a tragedy like the one involving David Kwiatkowski happens again.

I thank Holly Ramer from Associated Press for her piece on the sentencing and for offering another forum for the victims and their families to be heard. http://hosted.ap.org/dynamic/stories/U/US_HEPATITIS_C_OUTBREAK?SITE=AP&SECTION=HOME&TEMPLATE=DEFAULT
Too often the victims suffer quietly alone. It is important to understand they are real people living very real lives just like you or me. The scary part is if it could happen to them, it can also happen to you. I know this to be true because I was one of them just a few years ago.

I don’t think much about the surgical tech who infected me except when I hear tales of other outbreaks, other victims and other missed opportunities to keep patients safe. What I do think about is how my life has changed. I think of the other victims and what might have been had Hepatitis C not entered our lives in such a horrific way. And my heart goes out to each and every one wishing them the strength and support they will need to endure what lies ahead.