CDC report: Patients harmed after health-care providers steal patients' drugs

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 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 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, 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 potentially exposed to harm. The increasing incidence of makes it mandatory that drug control be improved."

More information: "Outbreaks of Infections Associated With Drug Diversion by US Health Care Personnel," by Melissa K. Schaefer, MD, and Joseph F. Perz, DrPH 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. dx.doi.org/10.1016/j.mayocp.2014.04.010

CDC Injection Safety/Drug Diversion: www.cdc.gov/injectionsafety/drugdiversion
CDC's Safe Healthcare Blog feature on drug diversion: blogs.cdc.gov/safehealthcare/category/safe-injection
CDC's Safe Injection Campaign: www.oneandonlycampaign.org
Medscape's CDC Expert Commentary on drug diversion: www.medscape.com/viewarticle/825801

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