N.H. hospitals learn from hepatitis C outbreak

New Hampshire health officials hoping to learn from the kind of drug diversion debacle facing Exeter Hospital got some detailed advice Thursday from out-of-state hospitals that have weathered similar incidents.

The New Hampshire Hospital Association invited officials from the Mayo Clinic in Minnesota and RoseMedical Center in Denver to share how they responded to drug diversion problems at their facilities.

In Minnesota, a nurse at a Mayo hospital in Mankato was accused in 2008 of stealing the powerful painkiller fentanyl and replacing it with syringes of saline solution, depriving surgical patients of their medication. In Denver, a former surgical technician is serving a 30-year sentence after pleading guilty in 2009 to similar allegations. Kristen Diane Parker, who got another job at a second Colorado hospital less than two weeks after being fired from Rose Medical Center, was also accused of infecting up to three dozen patients with hepatitis C through her drug diversion.

The Colorado case bears some similarity to the case of David Kwiatkowski, a former cardiac catheterization lab worker who is accused of stealing drugs from Exeter Hospital and replacing them with tainted syringes that were later used on patients. Thirty-two people have been diagnosed with the same strain of hepatitis C he carries since the investigation began in May.

Kevin Dillon, director of pharmacy services at the Mayo Clinic, said responding to such incidents requires a consistent, managed approach. Mayo now has a medical diversion prevention coordinator position as well as an eight-member team that meets within 24 hours of hearing about a suspected drug diversion case.

"You can't react to each one of these as if they're a new thing," he said.

After the 2008 incident, Dillon said Mayo performed a detailed analysis to identify risk points — medicationbeing left unattended, for example — and came up with more than 100 changes it could make. It also developed a list of 77 core structures and processes that it is working to implement in all its facilities. Even when that is done, drug diversion will still occur, he said, but the changes will make it harder.

"When it comes to diverters, 'They're smart, we're smart, they're desperate, we're not,'" he said, quoting a colleague. "So eventually we hope they slip up and we do catch them."

David Theil, an anesthesiologist at Rose Medical Center, said before the 2009 incident there, anesthesiologists frequently filled syringes for multiple patients to be better prepared before procedures.

"You were looked at poorly if you waited until the patient came in the room," he said.

It was an uphill battle to get those workers to accept changes made after the incident to ensure thatmedication wasn't withdrawn from dispensing machines until right before a procedure, he said.

In addition to strengthening its hiring procedures and making other changes, the hospital also has tried to enact broader cultural changes, said Robert Campbell, vice president of operations. Every staff meeting starts with a "safety moment" to discuss ways to improve patient safety, he said.

After the 2009 incident, "There were many feelings of guilt, of how could this have happened? How could I have allowed this vulnerability and how could I have potentially hurt somebody?" he said. "Quickly, we really had to get over that and say, it's really not about me, it's about the patients."

Since Kwiatkowski's arrest in July, Exeter Hospital has been hit with numerous lawsuits and the prospect of losing its Medicare funding if it doesn't fix problems uncovered during a federal inspection trigged by the outbreak of hepatitis C, a blood-borne viral infection that can cause liver disease and chronic health issues. It also has been wrangling with state public health officials over whether it has to release detailed medicalrecords the state is seeking as part of its investigation.

Kwiatkowski has pleaded not guilty to stealing drugs and tampering with needles.



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