A study published online Thursday said a nurse who tampered with syringes to obtain opioids was responsible for a bacteria outbreak in 2014 at the University Hospital in Madison, Wisconsin.
Five patients were infected with identical strains of Serratia marcescens, a gram-negative bacteria, according to the research published in Infection Control & Hospital Epidemiology, the journal of the Society of Healthcare Epidemiology of America.
After the bacteria outbreak, hospital staff discovered four hydromorphone syringes and six morphine syringes that had been tampered with in an automated medication dispensing cabinet.
The findings led to a controlled substance diversion investigation.
As part of the investigation, the hospital installed surveillance cameras at dosing machines. Footage showed Stefanie A. Jones switching syringe content. She was immediately terminated by the hospital.
Investigators who tested the tampered syringes suggest that Jones replaced the narcotics with saline which caused the infections. Other IV fluids within the hospital were tested and did not have evidence of the bacteria, suggesting Jones brought in the solution from outside the hospital.
Overall, hospital staff found 42 syringes with evidence of drug diversion. Jones pleaded guilty in February 2016 to four counts of possession of narcotic drugs. She was sentenced to five years of probation.
Four of the five patients were infected after brief post-operative stays in a post-anesthesia care unit where Jones worked. The fifth patient was Jones’ father who had been infected prior to being admitted to the hospital, according to Becker Hospital Review.
“This incident sadly adds to the handful of healthcare-associated bacterial outbreaks related to drug diversion by a healthcare professional,” said Nasia Safdar, a hospital epidemiologist and senior author of the study. “Our experience highlights the importance of active monitoring systems to prevent hospital-related drug diversion, and to consider this potential mechanism of infection when investigating healthcare-associated outbreaks related to gram-negative bacteria.”
Following the outbreak, the hospital implemented additional diversion security enhancements including tamper-evident packaging and additional security camera installations.
