Drug Diversion is Difficult to Identify, Impact on Patient Safety is Devastating

Recent events in Colorado and Utah underscore the difficulties hospitals have in preventing drug diversion.

In October 2015, McKay-Dee Hospital in Utah revealed that as many as 4,800 people had been potentially exposed to hepatitis C (HCV) after a state investigation linked the same hepatitis genotype from a patient treated at the hospital to a nurse who was caught diverting drugs in 2014.

A subsequent investigation by the Utah Department of Health found 15 additional cases of HCV linked to the outbreak, but health experts worried that there were still more unidentified cases, since only half of the patients notified of their potential exposure had been tested. Although officials did not specify how the infection was transmitted, an epidemiologist with the Utah Department of Health told the Deseret News “the most common way of transmitting hepatitis C is through needles,” leading to the overriding assumption that the nurse had diverted drugs and returned the used syringe for patient use.

Several months later, across the eastern border of Utah, a surgical technologist at Swedish Medical Center in Englewood, Colorado was fired for stealing fentanyl syringes in operating rooms. The surgical tech, Rocky Allen, who had been previously fired by four different hospitals in California, Washington, and Arizona, tested positive for a bloodborne pathogen. A subsequent investigation by the Colorado Department of Public Health and Environment (CDPHE) found no evidence of disease transmission among the 3,000 patients that were potentially infected, but cautioned the “absence of such evidence is not proof that no disease transmission occurred,” noting that approximately 1,000 patients still had not been tested.

These are just two of the latest incidents in which drug diversion has led to potentially devastating consequences for patients, highlighting an ongoing problem for healthcare facilities that can be nearly impossible to prevent, and often difficult to detect. And, according to Keith Berge, MD, and anesthesiologist at The Mayo Clinic in Rochester, Minnesota, and chair of the Mayo Clinic Medication Diversion Prevention Committee, it’s a problem that is happening in every hospital in the country.

This is an excerpt from Patient Safety Monitor Journal. Subscribers can read the full article here. Find out more about the journal, it’s benefits, and how to subscribe by clicking here.