CDC Report: Patients Harmed After Health Care Providers Steal Patients' Drugs
Impact of Drug Diversion Documented in Mayo Clinic Proceedings
Rochester, MN, June 2, 2014
When prescription medicines are stolen or used illegally, it is called drug diversion. One aspect of drug diversion that is not well recognized involves health care providers who steal controlled substances for their personal use. A report authored by experts from the Centers for Disease Control and Prevention (CDC) - published today in Mayo Clinic Proceedings - outlines outbreaks of infections that have occurred as a result of health care providers stealing or tampering with their patients' medications. These outbreaks revealed gaps in prevention, detection, and response to drug diversion.
“Patient harm stemming from diverting injectable drugs can include patients not obtaining adequate pain management, exposure to substandard care from an impaired provider, and exposure to life-threatening infections,” according to study co-authors Melissa K. Schaefer, MD, and Joseph F. Perz, DrPH, of the Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, CDC, Atlanta, GA.
Over the past 10 years, outbreak investigations related to health care provider drug diversion have documented more than 100 infections and nearly 30,000 patients potentially exposed to bloodborne or bacterial pathogens. The frequency with which these events have been detected appears to be increasing.
The review identified six outbreaks within hospital settings located in eight states over a 10-year period beginning in 2004. Implicated health care professionals included three technicians and three nurses. In four of these outbreaks the implicated health care professional was infected with hepatitis C virus and served as the source of disease transmission to patients. Two other outbreaks resulted from improper drug handling by drug-diverting health care professionals infecting patients with bloodstream bacterial infections.
“The outbreaks we have identified illustrate some of the devastating and wide-reaching impacts of drug diversion in US health care settings,” note Dr. Schaefer and Dr. Perz. “Health care facilities should ensure that patients safely receive medications as prescribed. This effort includes having systems in place to prevent drug diversion as well as developing protocols for early detection and appropriate response if, despite safeguards, diversion does occur.”
To prevent diversion, health care facilities should enforce strong narcotics security measures and maintain active monitoring systems. Appropriate response when diversion is suspected or identified includes prompt reporting to enforcement agencies and assessment of harm to patients, including assessment of possible infection risks.
“This report serves notice that all health care facilities that house controlled substances or other drugs of abuse must have effective systems in place that deter drug diversion,” comment Keith H. Berge, MD, and William L. Lanier, MD, Department of Anesthesiology, Mayo Clinic, Rochester, MN, in an accompanying editorial. “Further, those facilities must be able to quickly and effectively investigate when a drug diversion is suspected in an effort to limit the number of patients potentially exposed to harm. The increasing incidence of drug diversion makes it mandatory that drug control be improved.”
CDC provides several important resources for health care providers devoted to drug diversion:
- CDC Injection Safety/Drug Diversion: www.cdc.gov/injectionsafety/drugdiversion
- CDC’s Safe Healthcare Blog feature on drug diversion: http://blogs.cdc.gov/safehealthcare/category/safe-injection
- CDC’s Safe Injection Campaign: www.oneandonlycampaign.org
- Medscape’s CDC Expert Commentary on drug diversion: http://www.medscape.com/viewarticle/825801
Notes for editors
“Outbreaks of Infections Associated With Drug Diversion by US Health Care Personnel,” by Melissa K. Schaefer, MD, and Joseph F. Perz, DrPH (DOI: http://dx.doi.org/10.1016/j.mayocp.2014.04.007).
Editorial: “Bloodstream Infection Outbreaks Related to Opioid-Diverting Health Care Workers: A Cost-Benefit Analysis of Prevention and Detection Programs,” by Keith H. Berge, MD, and William L. Lanier, MD (DOI: http://dx.doi.org/10.1016/j.mayocp.2014.04.010).
Both appear online (openly available) in Mayo Clinic Proceedings in advance of Volume 89, Issue 7 (July 2014), published by Elsevier.
Full text of the articles is available to credentialed journalists upon request. Contact Rachael Zaleski at +1 215 239 3658 or email@example.com to obtain copies. To view an accompanying video presented by Dr. Joseph F. Perz go to http://youtu.be/-g2wGW1NN6g.
Journalists wishing to interview Dr. Schaefer or Dr. Perz should contact Melissa Brower, Public Affairs Specialist, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, at +1 404 639 4718, +1 404 903 0241 (mobile), or firstname.lastname@example.org. Journalists may contact Dr. Berge directly at email@example.com.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
About Mayo Clinic Proceedings
The flagship journal of Mayo and one of the premier peer-reviewed clinical journals in general medicine, Mayo Clinic Proceedings is among the most widely read and highly cited scientific publications for physicians, with a circulation of approximately 125,000. While the journal is sponsored by Mayo Clinic, it welcomes submissions from authors worldwide, publishing articles that focus on clinical medicine and support the professional and educational needs of its readers.
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