Aug 19, 2014 PNLR E-newsletter

Patients infected by tainted saline that nurse substituted for stolen pain meds

Courtney L. Davenport

A hospital patient who suffered horrific pain and a blood infection necessitating an arm amputation after a nurse took her pain medication and substituted contaminated saline has sued the hospital for medical negligence. At least 25 patients were sickened by the contaminated saline in 2010, including one who died. Several have lawsuits pending against the hospital.
 

In November 2010, Connie Tucker, 35, was admitted to St. Cloud Hospital (SCH) in St. Cloud, Minn., with an embolism in the brachial artery in her left arm. She was prescribed intravenous (IV) Dilaudid, a strong narcotic, but continued having “uncontrollable pain” after receiving the drug. Within three days of surgery for the embolism, her temperature soared, and her hand lost circulation. Over the next few weeks, she underwent two operations to amputate her arm as she battled pneumonia and two bacterial bloodstream infections. Nurses noted that she frequently appeared to be in pain even after they increased her Dilaudid dose.

After she was discharged, the hospital told Tucker that she contracted the infections because a nurse stole the Dilaudid meant for her and replaced it with tainted saline. Nurse Blake Zenner later admitted to accessing the IV narcotics bags from a locked box, using syringes to switch the substances, and using the narcotics while on duty. Of the 25 infected patients, six had to be moved to intensive care, three required additional surgeries, and one died. The hospital claims that patient was sick with many conditions and would have died regardless. Last year, Zenner pleaded guilty to fraudulently obtaining a drug.

SCH distributes narcotics through an Omnicell cart, which requires nurses to log on with a password to dispense drugs. Hospitals can create a “dispensing practices report” that compares dispensing rates among nurses. The Minnesota Department of Health later determined that although the hospital had been told in July 2010 that a different nurse was removing excessive doses of narcotics, it did not obtain dispensing reports. It also did not have a plan for identifying providers who are diverting drugs from patients or a method to trace drug distribution throughout the hospital.

“St. Cloud Hospital knew or should have known prior to November 2010 that Zenner accessed the narcotics keys significantly more than his peers, including accessing the keys on numerous occasions when he was not scheduled to provide care,” said Tucker in her complaint. The hospital also should have known “that Zenner repeatedly failed to properly document, waste, and/or account for narcotic pain medication that he had obtained from the St. Cloud Hospital pharmacy for administration to patients.” (Tucker v. St. Cloud Hosp., No. 73-CV-14-5834 (Minn., Stearns Co. Dist. filed July 11, 2014).)

Drug diversion by health care providers is a rampant—but downplayed—problem in hospitals. According to a recent USA Today analysis of government data and individual studies, 103,000 doctors, nurses, medical technicians, and aides were known drug abusers in 2007, the latest year for which there are data. But the number of actual drug abusers could be far greater: Just as in the general population, an estimated one in 10 health care providers will abuse drugs at some point—which would total about 500,000 providers nationwide.

One of those providers was traveling cardiac technician David Kwiatkowski, who injected himself with fentanyl meant for patients and then refilled the syringes with saline in 2007. He worked in medical facilities in seven states before Exeter Hospital in Concord, N.H., reported him to police after learning that several patients who had undergone heart catheterizations had contracted hepatitis C, which Kwiatkowski had previously been diagnosed with. At least 46 patients in four states tested positive for the disease, and thousands more in several other states required medical monitoring.

Many patients sued the hospitals and staffing agency that continually transferred Kwiatkowski to new hospitals even though he had twice been caught with stolen fentanyl syringes and failed subsequent drug tests, and staff at other hospitals had noticed him entering unauthorized areas and attending catheterizations during his off hours. Most of the plaintiffs have settled with the hospitals. Lynn Johnson of Kansas City, Mo., who represents several patients Kwiatkowski sickened at Hays Medical Center in Hays, Kan., said it’s far too easy for drug-addicted providers to access a hospital’s drug supply.

“Although there are supposed to be really strict standards and guidelines for protecting these drugs, hospitals are more lax than they should be,” said Johnson. “The [providers] are right there in a drug store, and if they are clever enough, they can get their hands on the drugs and place the patients at risk, both through diversion of drugs and through practicing while high.”

Kwiatkowski’s case illustrates what safety advocates say is a systemic failure to recognize drug-addicted doctors and keep them away from patients. As USA Today found, no state mandates drug testing for hospital workers, few states require facilities to alert law enforcement or regulatory agencies when they catch employees diverting drugs, and facilities rarely discipline providers until they have been caught multiple times.

Minneapolis attorney James Sheehy, who represents Tucker and another patient who contracted a blood infection at SCH, said drug testing should be mandatory for health care professionals, and hospitals should have a staff member devoted to preventing drug diversion.

“Addicted health care professionals appear to be an epidemic in our country,” said Sheehy. “The number of cases reported over the years establishes that not enough is being done to monitor diversions. Hospitals need to train staff to understand that diversions will be detected and prosecuted—deterrence does work.”