Patient Harm: The True Cost of Drug Diversion

When I entered the operating room, I noticed how cold it was immediately.  I looked around and saw some machines and a tray of surgical instruments.  There may have been a few medicines to help relax and reduce pain somewhere, but I did not notice. The procedure began and the anesthesiologist knocked me out.

In my anesthesia-induced slumber, I didn’t think about anything that could go wrong. The fear I had of going to the hospital to give birth to my daughter a year prior didn’t once return to my mind. I certainly would have never fathomed that I would contract an incurable disease and be the subject of an investigation that included 18 others with the same infection. In February of 2009, I had no idea what drug diversion meant. It was baptism by fire.

About 6 weeks later, I could no longer stand the extreme fatigue I was experiencing. While my kidney stone had been removed without issue, my ability to operate normally was deteriorating at a rapid rate. I felt as though I had the flu, but worse. If I was scared then, I can’t imagine how I would feel now during a pandemic. After yet another visit to Rose Medical Center, it was confirmed that I was positive for Hepatitis C. A Colorado Department of Health and corresponding CDC Investigation concluded that myself and others were infected with hepatitis C by a surgical technician at Rose Medical Center who had tested positive for the disease upon her hire at the hospital. She stole patients’ fentanyl-filled syringes off medication trays, injected herself with the controlled substance, then refilled the syringes with saline.

In addition to now being faced with overcoming an incurable disease, I also had no choice but to see certain gaps in the healthcare system. Back-to-back surgeries combined with the fast pace of the OR left a gap for medication unattended, making it extremely easy for the tech to gain access to the syringes, going virtually unnoticed.

The shortcuts that appeared to be taken didn’t surprise me. What surprised me is that the protocols and procedures which had been in place were not monitored or audited for compliance. Many hospitals have come a long way over the last decade, but as a professional in the mental health space, I am deeply concerned by the effect that the past year and COVID-19 pandemic will have on healthcare professionals who might be struggling.

The reality of it all is that, for diverters, getting caught is often the road to recovery. The tech in my case faced severe punishment. She posed an extreme risk to patient safety, my story above being just one account of the collateral damage. The report from the courtroom further points to the harm caused as a result of diversion, “Stealing fentanyl from operating room carts deprived surgical patients of needed anesthesia. At least one of her victims awoke mid-surgery in severe pain.”

While it’s never the patient’s responsibility to provide solutions for the consequences of a diverting healthcare worker, I can’t help but communicate a few ideas:

1. Create an easier reporting system for diverters. First, we need greater transparency and accountability — not just visibility into health care workers’ experience and career histories but also health care institutions’ investigations into suspicious activities. I’ve spoken about the invention of a national database to keep track of this.
2. Hold space for educational opportunities. Customer helplines have been a great start for patients to have accessible resources regarding their healthcare. Similarly, organizations working towards diversion mitigation should continue to create opportunities, like me sharing my story above, for healthcare workers, pharmacy professionals, and associated organizations to discuss diversion.
3. See something, say something. We need to reduce the institutional stigma associated with reporting diversion so that more leaders in healthcare organizations come forward and report when their employees are diverting.

Diversion hasn’t gone away, but we’re identifying it a lot easier than we were. Some health care systems track medications in barcode dispensing cabinets (where most medicine is stored and accessed) as evidence they’re addressing drug diversion. Unfortunately, that technology did not prevent or detect the diversion event in my case. With the advent of radio frequency identification (RFID) providers and pharmacy personnel have much more secure access and better visibility to all medication – including controlled substances – at the individual package level. This would have helped mitigate or even prevent the technician from diverting in the first place.

Lastly, a sign of progress is – we’re talking about it. There are easier reporting procedures and a softer place to land for diverters. It’s not a question of if a hospital will have a diversion problem, but when. If only patients would be thinking the same things about their own risks. But that is not the case as most patients enter a healthcare facility and place their trust in those who are there to care for them. But all hospitals know the risk, so the responsibility falls to them.