In May 2011, after several highly publicized cases of theft of controlled substances by healthcare workers in Minnesota, state health department officials approached the state hospital association with a plan.
Together they formed a coalition of people from hospitals, law enforcement agencies, long-term-care facilities and public health groups to collaborate on raising awareness, gathering data and developing a road map of steps to prevent so-called drug diversion.
“We looked to high-performing organizations that were already addressing the issue and we gathered those best practices,” said Tania Daniels, vice president of patient safety at the Minnesota Hospital Association.
While there are no exact statistics about the prevalence of drug theft in healthcare facilities, experts agree it's a pervasive problem. “It happens in all hospitals, but it's immensely under-reported and under-detected” said Kimberly New, founder of Diversion Specialists, in Knoxville, Tenn., who previously oversaw diversion prevention at the University of Tennessee Medical Center. “When I launched the program in 2007, I was catching three or four nurses a month,” New said. “But even seven years later with a well-established program in place, I was still catching one or two a month. It's extraordinarily widespread.”
New says hospitals should view diversion as a patient-safety issue, like falls, especially when theft involves injectable drugs and potential risk of infection for patients.
In 2012, a high-profile, multistate outbreak of hepatitis C affecting more than 40 patients was traced to David Kwiatkowski, a traveling medical technician working at 99-bed Exeter (N.H.) Hospital who stole syringes of the painkiller fentanyl, used them to inject himself, then refilled them with saline. Kwiatkowski pleaded guilty to 16 federal charges and was sentenced in December 2013 to 39 years in prison.
“One of the positive outcomes of the Kwiatkowski saga was that it raised awareness and compelled hospitals to take some action,” said Dr. Joseph Perz, quality and standards team leader at the Centers for Disease Control and Prevention.
Hospitals shouldn't wait until there is an infection outbreak to engage public health agencies, Perz said. “Anytime there is evidence of tampering, there needs to be a careful evaluation of infection risk, and that is not something hospitals should engage in on their own,” he said. “They don't need to work in a vacuum.”