Original articleOutbreaks of Infections Associated With Drug Diversion by US Health Care Personnel
Section snippets
Patients and Methods
The Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC) frequently assists health departments and institutions with investigations of outbreaks involving health care exposures, including drug diversion. We reviewed our internal records and CDC-authored reports related to US outbreaks from drug diversion by health care personnel for the 14-year period extending from January 1, 2000, through December 31, 2013. A PubMed search was conducted for outbreak
Results
We identified 6 outbreaks of infections that resulted from drug diversion by health care personnel in US health care settings in the past 10 years. Two outbreaks resulted in gram-negative bacteremia in 34 patients; the remaining 4 outbreaks resulted in HCV infection in 84 patients. All of the outbreaks occurred in one or more hospitals; these facilities were located in 8 states. Tampering with injectable controlled substances was documented or suspected in all of the outbreaks; fentanyl was
Discussion
Over the past 10 years, outbreak investigations have documented more than 100 infections and nearly 30,000 potentially exposed patients stemming from drug diversion in US health care facilities. The frequency with which these events have been detected appears to have increased; using similar methods, we identified 3 additional US outbreaks of this type in the previous 20 years.26, 27, 28 For HCV, drug diversion has emerged as the leading cause of health care transmission between infected health
Conclusion
Outbreaks of HCV and other infections have highlighted the need for system-wide improvements to address the problem of drug diversion in the health care community. Basic patient safety depends on effective, reliable safeguards to maintain the security of injectable medication in any health care setting.
Acknowledgments
The authors are grateful to the many public health and clinical partners who contributed to the investigations summarized in this article.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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2019, AORN JournalCitation Excerpt :Nurses who divert medications from patients may cause direct harm because the patient receives an insufficient dose. Although less common, HCWs who diverted medications (ie, RNs, CRNAs, radiology technicians, surgical technologists) have caused local outbreaks of infectious diseases (eg, hepatitis, bacteremia).15 In these outbreaks, the HCWs used a variety of diversion tactics and the patients subsequently injected medications that were contaminated with the diverter's blood.15
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