Protecting patients from injury due to drug diversion | Viewpoint

It hit close to home when I first learned about the case of David Kwiatkowski, a cardiac technician with opioid use disorder who transmitted hepatitis C to dozens of patients by contaminating medication vials at a New Hampshire hospital.

Tim Lahey, a physician ethicist at the University of Vermont Medical Center and advisory board member of Healthcare Diversion. (Photo: Healthcare Diversion)

As an infectious disease specialist, I see firsthand the devastation of opioid use disorder, hepatitis C, and other bloodborne illnesses. I also practiced just miles away from the hospital where Kwiatkowski worked, so my patients’ safety was just a matter of luck.

As the investigation unfolded, law enforcement learned that Kwiatkowski had been diverting hospital drugs for his own use for years, at Exeter Hospital in New Hampshire where the outbreak occurred — and beyond. Kwiatkowski had worked in 18 hospitals in eight other states before working at my hospital in Exeter, New Hampshire.

My heart went out to hundreds of patients who may have been exposed, unknowingly, to serious risk of major medical harm due to Kwiatkowski’s opioid use disorder. How had this man managed to secure job after job, even despite a trail of worrisome behavior?

Some of the answers are in a 2015 interview published by Newsweek with Kwiatkowski. He was in prison serving a 39-year sentence, and his story highlights multiple systemic failings, from temporary staffing agencies that brushed evidence aside to fill immediate workforce needs, to healthcare institutions that feared legal repercussions of reporting Kwiatkowski, to leadership that understandably wanted to avoid hassle and confrontation. There were so many opportunities to protect patients from Kwiatkowski’s drug diversion, and yet enough system obstacles that nobody did.

Understanding the risks of diversion – and how we’re falling short

Outbreaks of hepatitis C from healthcare worker drug diversion are not an anomaly. The Centers for Disease Control and Prevention have reported numerous outbreaks in the last few decades alone, despite a high likelihood of underreporting.

Hepatitis C infection isn’t the only way drug diversion can harm patients. Bacterial contamination of medication vials can lead to bacterial bloodstream infections. Plus, if a clinician with opioid addiction takes an opioid out of a vial and replaces it with a water, the dose of a pain control agent that the patient receives is too low. That can mean the patient continues to suffer and reports that their pain isn’t adequately controlled. If the subsequent dose is elevated by a different staff member, the patient could overdose because their body can’t handle an elevated dosage.

Additionally, if drug diversion results in healthcare worker intoxication on the job, patient safety can suffer from suboptimal care. Imagine being a vulnerable patient receiving medical care from a physician or other healthcare worker who is intoxicated!

A better way to vet healthcare workers

Despite a panoply of opportunities to prevent patient harm from drug diversion, not much has changed in the years since Kwiakowski went to prison for his role in the New Hampshire hepatitis C outbreak.

In fact, healthcare organizations likely face a greater risk of healthcare diversion than they did in 2015, as the opioid epidemic has exploded since the 2010s.

More than 112,000 individuals died of opioid overdoses in the U.S. over the last 12 months, according to provisional CDC data. Paired with rampant physician shortages from post-Covid burnout, staffing agencies and healthcare employers feel the pressure to fill vacancies – and may overlook extra background checks.

Clearly healthcare organizations cannot rely on state licensure processes to protect patients from drug diversion. Too many outbreaks have followed spotless licensing. Healthcare executives must take more responsibility in their role in preventing diversion – from the time they hire someone, to reporting on former employees’ suspected drug diversion.

Yet, if systems obstacles to responsible reporting remain, I fear nothing will change and another generation of drug diversion-related outbreaks will follow.

Employ evidence-based practices

Fortunately, it is getting easier for healthcare leaders to discharge their duty to protect patients from healthcare worker drug diversion. A handful of states are making strides toward more transparent hiring practices of healthcare workers.

New Jersey recently passed the Cullen Law, which requires employers to report to state medical boards if a former employee is under investigation of suspected drug diversion. This is a good start, but we need national efforts to truly make an impact since so many healthcare workers travel between states as they switch jobs. This is particularly true in the pandemic era of healthcare worker shortages and the consequent massive expansion of reliance on traveling healthcare workers.

State health regulatory bodies, nursing boards and the Joint Commission should support strong rules and guidelines that minimize the risk of diversion. For example, The Joint Commission could require that suspected incidents of diversion among colleagues are reported to law enforcement. Clinical licensing bodies can be more specific about the sorts of background checks required to prevent unreported drug diversion.

Cullen Laws and beefed-up Joint Commission requirements are just a start. We need a national centralized reporting system into which healthcare organizations are required to log incidents of reported diversion and which human resources managers can access as part of due diligence background checks.

This nationwide repository can aggregate information submitted by healthcare institutions about employees suspected of engaging in drug diversion, from confirmed reports investigated by law enforcement to suspicious behavior that was not fully confirmed to be drug diversion. With the right privacy protections in place, and transparent indicators of the level of certainty associated with a report, employers would be able to protect the patients under their care better than they do now..

This isn’t just a pipe dream. The nonprofit HealthcareDiversion.org, for whom I serve as a volunteer advisor, is already developing the foundation for a national centralized database of drug diversion.

HealthcareDiversion.org already enables individuals to report suspected incidents of diversion, anonymously — including the name of individuals suspected of drug diversion – anonymously. This database can be accessed by healthcare organizations and law enforcement agencies nationwide, who can sign up for push notifications, so they’ll be apprised of any incidents in their communities.

To be sure, there is an important risk of reputational damage to individuals who are wrongfully accused of drug diversion. Any national system must, like HealthcareDiversion.org, carefully vet all reports of suspected or confirmed drug diversion and indicate in their records whether reports are substantiated.

Also, beyond the patient safety protections that such a national repository can achieve, reporting can help connect healthcare workers involved in diverting drugs to non-punitive resources for care. Speeding up access to lifesaving treatments and rehabilitation programs can help bring valuable healthcare workers back to the workplace and to gainful employment after evidence-based treatment for opioid use disorder Protecting the health of others, whether clinicians or patients, is our first call of duty as health leaders, but it need not come at the cost of healthcare worker safety.

There is no magic bullet for drug diversion. It will take concerted effort. Strengthening our national, statewide and organizational defenses against diversion through greater transparency and more careful hiring practices is just the next logical step toward protecting patients from the hepatitis C outbreak like the one at Exeter Hospital in New Hampshire.

Tim Lahey, MD, is an infectious diseases physician and ethicist at the University of Vermont Medical Center. He is a volunteer advisor for HealthcareDiversion.org.