Nurse Addicted to Drugs Considered the Source of Hepatitis Outbreak
After the Centers for Disease Control and Prevention (CDC) became aware of a hepatitis C outbreak among patients in a Washington state hospital, a nurse addicted to drugs admitted to diverting and using injectable narcotics intended for patients.
One of the patients receiving injectable narcotics from the nurse was known to have chronic hepatitis C (HCV). It is thought that this patient may have been the source from which the nurse acquired the virus.
The nurse is believed to have treated and infected 12 patients after acquiring the virus from the patient with chronic HCV. Those patients were given opioid injections in the emergency room where the nurse worked.
According to the CDC, the nurse was the only “common epidemiologic link” to the patients who developed a “genetically similar strain of hepatitis C” and were probably infected from a shared needle or other injection equipment first used by the infected nurse before injecting the patients.
It was discovered that the nurse, who admitted to diverting patients’ injectable narcotics for personal use, had accessed the hospital’s automated dispensing system more often than other staff members.
During the time period from August 2017 to March 2018 when the nurse worked in the hospital’s emergency room, the hospital identified and then notified 2,985 patients who received injectable drugs (opioids, sedatives, or antihistamines) from the nurse while she was on duty.
The nurse has since had her license suspended by the state’s nursing commission.
The CDC advises that “Health care facilities and public health partners should recognize the potential for infections and other harms from drug diversion and minimize risks by storing controlled substances securely and routinely scrutinizing drug access logs.”
Compliance Perspective
Failing to minimize the potential risks of infections and other harms by storing controlled substances securely and scrutinizing drug access logs routinely may be considered substandard quality of care and violate state and federal regulations.
Discussion Points:
- Review policies and procedures regarding the storage and securing of controlled substances.
- Train staff on the protocols for securing controlled substances and maintaining accurate drug access logs and for preventing the spread of infection through proper use and disposal of all devices used to inject medications.
- Periodically audit the drug access logs on all shifts to ensure that established protocols for secure storage and accounting for narcotics is being followed.
