February 27, 2018

How drug diversion can enable patients to unknowingly become infected with Hepatitis C

Perhaps this is a question you have never thought to ask, and before April of 2009 it was not even in the realm of curiosity for me either. But as I entered Urgent Care for what I thought might be bronchitis or something similar, only to be asked by the medical assistant, “Do you know you are yellow?” my world was immediately turned upside down. A trip to the ER and several other doctor’s visits and blood tests later confirmed I had Hepatitis C.

The diagnosis hit me like a ton of bricks. This could kill me, right? This was my first thought and then I thought of Lucy, my 1-year-old daughter. Had I also infected her? What would she do if something happened to me? As a single parent, I did have a plan as a precaution, but never in my wildest dreams did I think I would ever need to use it. Hepatitis C? How does a healthy 41-year-old get Hepatitis C? No IV drug use, no blood transfusions, no sexual partners who may have been exposed.

I was relentless in my pursuit to get answers: How did this happen and how do I get rid of it?

But now I realize I was simply asking the wrong questions. I had a routine surgery about 6 weeks prior and although I noted this in every interview by every healthcare professional, they were slow to connect the two. But I kept going back to the same conclusion, how could it not be the hospital? But the scarier question was if I was infected, how do we know others were not as well?

If it could happen to me, it could happen to others

The news broke in the beginning of July about the arrest. A hospital employee who had tested positive for Hepatitis C had been diverting syringes of fetanyl, injecting herself and then filling the syringe with saline and putting them back on surgical trays to be administered to patients. I was one of 19 patients who had fallen prey to her deadly scheme. I was one of thousands of patients who might have been infected because a surgical tech was able to figure a way to fool the hospital systems and feed her addiction with no concern for patient safety.

The system at the hospital had been very broken and thousands of patients and hospital employees were put at risk. And while it was easy to say that this was the work of one rogue employee, I knew this was not the case. If the systems were not fixed, more people would be put in harm's way. So I began to speak out to anyone who would listen. I began to tell my story and help the public to understand I was just like them. I went in for a simple surgical procedure and I came out with Hepatitis C. If it had happened to me, it could happen to them and changes needed to be made.

We know so much more now than we did in 2009 when the outbreak occurred. However, incidents of diversion have not decreased.  Technologies are available that leave little to human error or oversight. When coupled with the “see something, say something” mentality, these can help prevent and outline signs of possible drug diversion.

The surgical tech at the center of this Hep C outbreak was able to find a way around the hospital’s system within the first couple days of her employment.  In addition to her easy access to drugs, it was documented that there was a 30 minute gap between when the syringe of fetanyl was unlocked from the cabinet until when it was to be used during my surgery.  Where it was in those 30 minutes is anyone’s guess.

It should never be this easy for someone to ruin so many lives.  Healthcare organizations need to take the critical steps to better understand how their workers are moving through their system and eliminate the possibility for them to divert drugs.  Once healthcare leaders understand their organization’s vulnerabilities, they can then implement measures to better protect their workforce and patients.

To learn how drug diversion is impacting healthcare's workforce and patients, request the Protenus Diversion Digest.

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