An emerging report faults the New Hampshire hospital at the center of a hepatitis C scare. As we recently wrote, a lab technician was charged in a New Hampshire hepatitis C outbreak linked to Exeter Hospital’s Cardiac Catheterization Unit. Dozens of patients were infected with the dangerous virus.
The report, issued by the federal Centers for Medicare & Medicaid Services, states that cardiac catheterization laboratory nurses left syringes unattended, wrote Boston.com. In response, Exeter Hospital, in the report, said it has changed its policy and is placing syringes in a secure location, where they will remain locked during times when medication is not being administered to patients.
An investigation by state health regulators was initiated at Exeter Hospital in June after the hepatitis C outbreak in patients was reported. Former hospital technician David Michael Kwiatkowski, 33, was accused of stealing drugs from the lab, infecting 31 patients with contaminated syringes. Kwiatkowski, who is also infected, was previously a traveling medical technician, having worked in at least 18 hospitals in eight states.
Kwiatkowski faces charges in the outbreak that originated with his fraudulently obtaining controlled substances and tampering with a consumer product, according to U.S. Attorney John P. Kacavas. “The evidence gathered, to date, points irrefutably to Kwiatkowski as the source of the hepatitis C outbreak at Exeter Hospital,” Kacavas told Reuters previously. “With his arrest, we have eliminated the menace this ‘serial infector’ posed to public health and safety.” Kwiatkowski worked in the lab until May, when the investigation was initiated. He is accused of stealing syringes filled with Fentanyl, a very powerful pain drug. Kwiatkowski would inject himself with the Fentanyl, replacing patient medication with saline solution. The tainted, diluted solution would then be injected into patients, said Kacavas.
The report stated that a nurse at the hospital was asked to demonstrate the syringe and blunt tip needle type commonly used, and how syringes are labeled with the name of the medication used. The nurse then showed how to withdraw drugs from a “Pyxis machine.” The cart is constructed with a finger print scan and a password, explained Boston.com. Once accessed, the machine dispenses a vial with 2 milligrams of medication, which is then drawn into the syringe.
The failure, said the review, occurred after drugs are dispensed from the machine and the medicine was placed on an unsecured cart in the lab where technicians “who do not have authority to handle medications” have access, explained Boston.com. The medication could be left unattended while staff was donning a lead apron, for example, the review found. The new policy, implemented last month, states that, once drawn, syringes must be placed in a secure draw within the Pyxis machine, until needed.
Although Kwiatkowski’s name, nor any other staffer’s name, is not mentioned in the report, it mentions that in a June 7 interview with a catheterization lab manager, that one technician had three open lesions and a finger cut requiring stitches during the staffer’s employment from date of hire—April 11, 2011—until May 16, 2012. These dates are the same as Kwiatkowski’s employment dates, said Boston.com. New Hampshire health official, John Martin, confirmed Kwiatkowski is the employee referred to as having skin lesions.
In fact, the report indicates that investigators learned from the June 7 interview that the staffer “was asked to leave the work area several times due to weeping/discharge of fluids and blood-like stains” on his/her scrubs, including at least one time during a patient procedure, said Boston.com. The report also mentions a hospital report from September 2011 that stated this staffer’s incision bled multiple times, requiring medical care. The wound was healing as of March.
Kwiatkowski, who was fired on May 25, faces a 20-year prison sentence for drug tampering and up to four years for the controlled substance charge.
Hepatitis C is a viral liver disease that can cause inflammation of the liver and can lead to chronic liver disease, such as cirrhosis, or cancer of the liver. The virus is spread by contact with infected body fluids; no vaccine exists for hepatitis C, which can be fatal.