A Bigger Problem Than Perceived
In a paper published Monday in Mayo Clinic Proceedings, Schaefer and Perz report findings from their extensive review of CDC records, including unpublished reports, to crunch some numbers. They've concluded that healthcare worker "tampering" with patients' medications has resulted in 118 patients infected in the last 10 years in six episodes, more than expected.
Of those six incidents, four have occurred since 2008, affecting 84 patients and indicating a mushrooming problem. For the healthcare facilities involved, the workload was enormous and devastating to institutional reputations. In total, some 30,000 patients put at risk by the four most recent incidents had to be contacted for testing, and had to deal with the emotional and practical repercussions of possible exposure to infection.
Perhaps best known is the nightmare of David Kwiatkowski, a traveling catheterization lab technician now serving a 39-year prison term. He was convicted in December, 2013 of stealing the drug fentanyl from syringes he first used on himself. His theft and disregard for patients transmitted his hepatitis C infection to some 45 unsuspecting patients undergoing procedures, including one who died.
Kwiatkowski, had worked in as many as 12 hospitals in eight states, though suspicious behavior prior to his capture went unreported. Finally in 2012, a cluster of infections at a single, small facility led investigators to his employment at the 100-bed Exeter Hospital in New Hampshire.