Nurse Article
Hospital Suspects Nurse's Drug Diversion Caused Bacterial Infections
Unidentified nurse allegedly used syringe to steal patients' IV pain medications.
Officials at a Minnesota hospital suspect that a nurse may have inadvertently infected dozens of patients with bacteria not normally found in people by stealing and tampering with patients' IV pain medications.
So far, 23 patients who received care in the same unidentified unit of St. Cloud Hospital between October and early March have been treated for symptoms of unusual bloodstream bacterial infections. The hospital identified the bacteria Ochrobactrum anthropi and Klebsiella oxytoca, which are found in the air and on surfaces but not usually in people, as the culprits. None of the patients became seriously ill and all were treated with broad-spectrum antibiotics, the hospital reports.
"It was unusual," says Beth Honkomp, director of quality and patient safety for St. Cloud Hospital, of the increase in positive blood cultures for the bacteria detected last month. "This organism isn't typically found in the blood of human beings, and so we needed to investigate further," she told the St. Cloud Times. The hospital began working with the state health department and the Centers for Disease Control and Prevention and identified drug diversion as a potential cause of the infections.
The bacteria were discovered growing in at least 2 medication bags. Meanwhile, a supervisor reported suspicions about a nurse, who then turned up for work on her off day, trying to access the narcotics cabinet, according to the Times. The nurse, whom the hospital has declined to name, agreed to a drug test and has been suspended pending a criminal investigation into her alleged role in the infections.
Officials suspect that the nurse used a syringe to remove pain medications from patients' IV bags for her own personal use and covered her tracks by replacing the meds with air or saline.
The hospital says it took a "series of immediate steps" in response to the incident, including replacing all patient-controlled IV bags containing pain medications, testing them for the presence of bacteria, testing multiple potential sources of the bacteria (both supplies and environment) and evaluating "individual employee and hospital-wide practices for managing and administering narcotics." Ms. Honkomp tells the Times that IV bags are now double-bagged, with an outer layer that more clearly shows signs of tampering.
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March 18, 2011
