Hospital faulted for poor drug security, dirty equipment in hep C outbreak

In the wake of investigations into the "serial infector" who allegedly started a hepatitis C outbreak, a Centers for Medicare & Medicaid Services report revealed that Exeter Hospital failed to secure narcotics and clean equipment in between patient uses, Reuters reported.

The CMS report revealed how former employee David Kwiatkowski was able to divert drugs at the New Hampshire community hospital, which has been at the center of a media storm and class-action lawsuit. CMS detailed how the traveling lab technician stole syringes filled with the painkiller Fentanyl, injected himself, then refilled the contaminated needles with saline for other patients to use.

Exeter Hospital not only had poor narcotic control, but it also lacked a policy for cleaning glucose monitors--a source of infection that is only now being realized, HealthLeaders Media reported.

Still, Exeter Hospital's President and CEO said he's proud of how the staff handled of the situation. Kevin Callahan said that when physicians affiliated with Exeter Hospital in May identified the hepatitis C strain, the internal risk assessment team followed up immediately and notified the New Hampshire Department of Public Health, he wrote in the New Hampshire Union Leader.

"I am proud of the way our staff has handled this tragic situation. We stopped Mr. Kwiatkowski from working. We immediately notified authorities, and we have been assisting investigators ever since."

Exeter's corrective action plan states that nurses now must lock up syringes, once filled, and only unlock them when needed. That will add additional time to the treatment process but makes pain medication more secure in the cardiac catheterization lab.

Callahan reiterated the other hospitals who previously fired Kwiatkowski did not follow through on reporting and notification.

"[A]s at least a dozen hospitals in eight states where Mr. Kwiatkowski previously worked consider whether they need to test patients for hepatitis C, it is becoming clear the U.S. healthcare system needs to do some soul-searching about an employee whose alleged behavior in my view, verges on domestic terrorism," he wrote.

Meanwhile, Exeter Hospital last week added a fourth additional testing clinic, The Boston Globe reported.

Thirty patients and one hospital employee had been infected with the same strain of hepatitis C as Kwiatkowski, Reuters reported.

"Its reach is unprecedented, and we're the tip of the spear in the investigation," John P. Kacavas, the United States attorney for New Hampshire, told The New York Times. "In terms of volume, scope and intensity of work involved, it's a mammoth effort."

For more information:
- read the HealthLeaders article
- read the Callahan commentary in the Union Leader
- see the Reuters article
- here's the Boston Globe article
- read the NYT article
- check out the Exeter statement (.pdf) on the CMS survey and the corrective action plan (.pdf)

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