Health officials in at least three states are investigating a travel nurse suspected of tampering with and potentially contaminating vials and syringes of opioid painkillers in two hospitals, then returning the vials to medication cabinets where they could be unknowingly given to patients.
One hundred patients who may have been exposed to contaminated syringes last year at Johnson City Medical Center in Tennessee were urged to get tested for hepatitis and HIV, according to state documents obtained by KHN through a public records request.
The documents also reveal that Raleigh General Hospital in West Virginia this year gave vials to law enforcement to test for evidence of tampering. Those results haven’t been made public.
The travel nurse, Jacqueline Brewster, 52, of Belfry, Kentucky, was arrested by her local sheriff’s office on undisclosed charges Tuesday in response to a fugitive warrant from Washington County, Tennessee, where the allegations of tampering began, according to jail and court records. Brewster was released Wednesday with orders to report to Tennessee within 10 days.
“I didn’t run away from anything,” Brewster said in court. “I don’t know how I’m a fugitive.”
According to documents filed by Tennessee and West Virginia health authorities with their respective nursing boards, Brewster is suspected of repeatedly opening hospital medication cabinets to withdraw vials or syringes of an opioid painkiller, Dilaudid, allegedly removing some of the drug to either use or steal, and then returning the vials or syringes, possibly after gluing a cap back on. The CEO of one of the affected hospital systems alleged in an interview with KHN that the travel nurse added another liquid to syringes — possibly in an attempt to cover her tracks.
The allegations against Brewster, which have not been previously reported, come at a time when the coronavirus pandemic forced many U.S. hospitals to rely more than ever on travel nurses, who often cross state lines to work months-long stints in short-staffed hospitals. As the virus flooded hospitals with patients and worsened nursing shortages, many hospitals turned to travel nurses to fill the gaps, often at a dramatically increased cost.
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But “desperation” to recruit nurses also exacerbated existing flaws in the government infrastructure intended to hold nurses accountable, said John Benson, co-founder of Verisys, a data management company that researches potential employees for healthcare systems.
Nurses and other medical professionals are licensed, investigated, and disciplined at the state level. But investigators don’t communicate well across state lines, Benson said, so as more nurses began to travel during the pandemic, it became easier to “outrun” investigations by getting a new job in another state long before allegations of wrongdoing became public.
“The system was broken before COVID,” Benson said. “It just got more broken during COVID.”
Brewster, a registered nurse, has been licensed in Kentucky since 2004 and holds a license permitting her to work in more than 30 states that participate in the Nurse Licensure Compact. After she was accused of tampering at Raleigh General last month, the West Virginia nursing board suspended Brewster’s ability to practice in the state. Days later, Tennessee health officials acted on a complaint they received from Johnson City Medical Center last July, launching a professional disciplinary proceeding that could revoke Brewster’s ability to work in that state later this year.