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.
Some may remember the actions of a traveling tech who was finally stopped in Exeter, NH after working in 19 hospitals in 8 states. People asked, “How can this happen?” “Why was he not caught sooner?” These are the same questions being posed in the Colorado case.
Drug diversion is a universal healthcare issue. It happens and we shake our heads. It is under-detected and underreported. With both cases, had the previous hospital taken action, perhaps involved local law enforcement, perhaps allowing the state health department further investigation, making the diverter accountable for their actions rather than allowing them to leave the hospital and move on to potentially harm other patients, the risk and exposure would have been contained.
Instead we sit by and wait as more and more patients are notified of possible exposure. Until reports of a bloodborne pathogen hit the news cycle, I was hoping this event at Swedish Medical Center might not turn into another outbreak. But now, we wait to hear who may have been infected. Truly heartbreaking, indeed.
The proposal on the table may not be about total prevention at this point. The occurrences of drug diversion are vast and varied. But it is about early detection. It is about hospital administrations working in tandem with law enforcement. It is about encouraging recovery and treatment. It is about transparency within a hospital with staff and outside with the public offering education. It is about a better way of auditing the dispensing of these drugs and a regular review, perhaps with outside agencies, to insure compliance.
And it is about a central reporting location. A database to which hospitals and healthcare facilities can go pre-employment to see if what a potential employee reported about past work history is correct; to be able to easily check and see if there have been past firings, or disciplinary actions involving drug violations. It is also about drug screening and background checks.
After the events at Exeter hospital, New Hampshire passed legislation that not only requires med techs to be registered but also state and FBI background checks. A similar amendment is up for review in Colorado. In the meantime, organizational meetings are being planned for several key players in the drug diversion, safe injection, healthcare and patient safety advocacy fields to continue discussions regarding a national registry.
For more information about safe injection practices and drug diversion education please check out the CDC’s One and Only Campaign www.oneandonlycampaign.org
and the International Health Facilities Diversion Association www.ihfda.org
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