In 2010, a surgical scrub technician named Kristen Parker was sentenced to thirty years in federal prison after allegedly diverting fentanyl from operating rooms, injecting herself with the powerful intravenous narcotic, refilling the contaminated syringes with saline, and replacing them to be used on patients.  She was infected with hepatitis C, and her drug diversions infected over two dozen patients in the Denver area.

In 2012, David Kwiatkowski, also positive for hepatitis C, allegedly carried out the same unthinkable acts as Kristen Parker.  His drug diversion activities potentially placed patients in seven states at risk for the development of hep C.  7,900 patients had to be tested for the disease.  To date, over 40 patients have tested positive for the same strain of hepatitis C as that infecting Kwiatkowski.  He is currently in jail in New Hampshire, awaiting trial.

Also in 2012, a prominent Denver oral surgeon, Dr. Stephen Stein, was discovered to be reusing needles and syringes on his patients.  All patients who received intravenous sedation while under the care of Stein from September 1999 to June 2011 are potentially at risk for HIV, hepatitis B, and hepatitis C.  It was later alleged by Stein’s partner, Neil G. Dobro, D.M.D., that Stein had been “getting high before performing surgeries” and reusing needles.  Stein has relinquished his license as an oral surgeon in Colorado and is currently being investigated by the Denver Police Department for prescription drug fraud.

In March 2013, another shocking story emerged involving Tulsa, Oklahoma dentist, Dr. Wayne Harrington.  Purportedly, Harrington used unsterilized instruments on patients in his practice.  Over 7,000 patients were recently notified that they were at risk for infection with HIV and hepatitis.

Although each of these examples varies slightly from the other, they all beg the same question.  Can we ever eliminate the possibility of patients becoming infected with potentially deadly diseases at the hands of reckless caregivers?  As a physician, I would argue that, sadly, the answer is no.  While the diligence of principled healthcare workers is one very important line of defense, it means very little in the presence of a devious mind.  In the fluid and oftentimes chaotic setting of a medical practice or a hospital, there is no practical way to monitor every worker every second of the day.  Furthermore, there is no reasonable way to prevent someone whom is intent on committing a heinous crime from seizing that window of opportunity.  Our only hope is to learn from these criminals and to close the loopholes that allow them to prey upon the innocent.

We can begin to minimize the risk to patients by enacting policies that diminish the opportunity for events like drug diversion or reuse of contaminated equipment to occur.  For example, better communication with interstate databases and more thorough background checks may have prevented Parker and Kwiatkowski from being hired time and time again, thereby keeping them from perpetrating the crimes that hurt so many.  More stringent rules on the storage of narcotics could also minimize access by employees who happen to be addicts.  If all healthcare employees were subject to random drug screens, including nurses and physicians, many users could potentially be discovered before patients were harmed.  Perhaps more attentive peer review by Stein’s and Harrington’s partners and nursing staff may have caught their dangerous practices much earlier.  These suggestions are only the tip of the proverbial iceberg.  We have a long way to go.

One thing that must happen is that such policies need to be implemented in a nation wide, standardized format.  In order to be effective, rules need to be the same from one institution to another.  It is the current state of inconsistency of rules between facilities that makes us vulnerable.  It is this vulnerability that will keep us from winning this deadly game of cat and mouse.

Sherry Gorman is an anesthesiologist.  In 2009, she was sued for medical malpractice after a drug-addicted scrub technician diverted fentanyl and allegedly replaced stolen syringes with contaminated ones refilled with saline.  The scrub tech’s crimes are blamed for infecting over two dozen patients with hepatitis C.  One of those patients was under the care of Dr. Gorman.  Her case settled out of court in January 2012.  Since that time, she has slowly started to heal.  Part of that process involved writing a book under the pen name Kate O’Reilley.  Dr. Gorman hopes that through her book and speaking out to other physicians, she can bring something good out of a situation that nearly destroyed her.