Home E-Weekly July 18, 2017

Nurse's Drug Theft Leads to Infection Outbreak, Patient Death

Published: July 17, 2017

NUMEROUS VICTIMS Six people, including the nurse's father, were infected.
Note: Photo is for illustration only. The person depicted is a model.

A drug-pilfering nurse was responsible for a 2014 outbreak of Serratia marcescens that led to one patient death and sickened 5 others at a Wisconsin hospital, according to a study recently published in Infection Control & Hospital Epidemiology.

The outbreak, which occurred over a period of 6 weeks, attracted attention at the University of Wisconsin Hospital, because the facility usually has fewer than 10 such infections per year. Hospital staff discovered that 4 hydromorphone and 6 morphine patient-controlled analgesia syringes in an automated medication dispensing cabinet had been tampered with. Eventually, another 32 syringes were linked to evidence of drug diversion. All had been filled with saline or other solutions instead of medication. The nurse, who worked in the PACU, was eventually identified and immediately fired.

One of the affected patients was the nurse's father, who lived with her before he was hospitalized with the infection. Four of the others were exposed in the PACU, shortly after the nurse accessed cabinets with contaminated syringes. All but one of the patients ultimately recovered.

Serratia marcescens, which can lead to infections in the urinary and respiratory tracts and the eye, has also been linked to heart and bone infections, pneumonia and meningitis. It's resistant to several antibiotics.

"Our experience highlights the importance of active monitoring systems to prevent hospital-related drug diversion," hospital epidemiologist Nasia Safdar, MD, PhD, says in a press release, adding that drug diversion should be considered as a "potential mechanism of infection when investigating health care-associated outbreaks related to gram-negative bacteria."

Jim Burger

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