I want to start this post by saying “Oops, it happened again.” The problem is, I shouldn’t have to blog about this topic considering how serious it is and the potential risk to patients.
I live in Colorado. In February, 2016, it hit the news that one of the Denver areas largest hospital, Swedish Medical Center, was testing close to three thousand patients for possible exposure to HIV and Hepatitis after a surgical tech was suspected of diverting drugs.
What is drug diversion? Drug diversion is using a narcotic for anything other than its intended use. The most mildest form is not wasting drugs properly. It requires two licensed personnel to waste a drug and sometimes you just can’t find another person at that moment and then you forget. Not excusable but understandable. The most serious form is healthcare workers using the drug themselves and not giving them to the patient or using the “waste” or overage for themselves.
The problem is, a relatively similar scenario happened at another Colorado hospital in 2008 and 2009. This was the case of Kristen Parker, a surgical tech who is currently serving a thirty year prison term for infecting three dozen patients with Hepatitis C. She was stealing unlocked Fentanyl set aside for surgery, injecting it into herself, and then drawing up saline into the same syringe where then an unsuspecting provider injected it into the patient causing transmission of the virus.
In fact, one of the anesthesiologists involved in this case went public and even wrote a novel based upon her experience. This wasn’t a quiet news story.
In this blog piece from The Daily Beast in February, 2013, Gorman states:
“At that time, we didn’t think about locking drawers,” she says. “No one ever told me I was doing anything wrong. If there were rules to enforce locking the drugs up, they were not enforced.” Rose has said it sent memos to its anesthesiologists in 2001 and again after Parker’s crime, warning them “never leave controlled substances unlocked or unattended.”
In light of this incidence, it is unbelievable to me that a case of suspected drug diversion involving a surgical tech could happen again in this state and it makes me wonder if potentially the same process of drug diversion was used as Kristen Parker employed– unsecured narcotics awaiting injection for surgical procedures.
The tech, Rocky Allen, has been arrested and has pleaded not guilty. Thus far, it appears two patients have tested positive for Hepatitis B.— although the hospital currently denies they transmitted the virus as part of this case.
So please, hospital OR’s everywhere, can we please develop a system where narcotics can be dispensed safely to surgical patients?