Better licensing urged after hepatitis C case
By ERIC TUCKER
WASHINGTON -- Staffing agencies that find jobs for health care professionals should be required to obtain a license and hospitals must do more to prevent drug abuse and theft by workers, the Maryland state health department said Wednesday.
The recommendations were included in a report issued in response to the case of a traveling health worker accused of exposing patients in Maryland and other states to hepatitis C. Described by prosecutors as a "serial infector," David Kwiatkowski is charged in New Hampshire with stealing syringes of a powerful painkiller for his own use and replacing them with saline-filled syringes tainted with his blood.
The recommendations by the state Department of Health and Mental Hygiene are aimed at closing loopholes authorities said enabled Kwiatkowski to travel from state to state as a cardiac technologist despite a checkered employment history that included allegations of drug use and theft. He worked in the catheterization lab at HaysMed from May 24 to Sept. 22, 2010.
The report said the outbreak exposed weaknesses in licensing and oversight of staffing agencies, in the licensing of health care professionals and in risk management practices -- such as detecting and preventing theft and abuse of narcotics -- at hospitals.
The report said staffing agencies that place technologists like Kwiatkowski should be licensed, just as state law already requires that nurse staffing agencies by licensed. Maryland lawmakers are considering such legislation.
The agency also is calling on the state Board of Physicians to review its procedures for licensing health care professionals, noting Kwiatkowski falsely obtained a radiographer certification and a Maryland license because no one verified what he had put down on his applications. Hospitals also should keep better track of their drug supplies, the report said. It suggests health care facilities tally up the amount of injectable narcotics dispensed and wasted after procedures and lock down the room if any drugs are found to be missing.
Hospitals and staffing agencies failed to properly screen Kwiatkowski before hiring him, underscoring the need for better information-sharing about prospective hires, the report said.
"Our review also revealed that hospitals and staffing agencies either did not disclose Mr. Kwiatkowski's conduct to one another, or favorably represented his job performance to one another, despite evidence of risky conduct, thereby obscuring the risks that Mr. Kwiatkowski posed," the report said.
He was employed from 2008 through 2010 at four Maryland hospitals. There have been five documented cases of hepatitis C infection involving patients at two of the Maryland hospitals where Kwiatkowski worked. There are six in Kansas. More than 1,700 patients at the hospitals have been notified of potential exposure.
Kwiatkowski is accused of stealing syringes of the powerful painkiller fentanyl from the cardiac catheterization lab at New Hampshire's Exeter Hospital and replacing them with saline-filled syringes tainted with his own blood. In jail since his arrest in July, he pleaded not guilty to 14 federal drug charges in December and is expected to go to trial next fall.
Before April 2001, when he was hired in New Hampshire, Kwiatkowski worked as a traveling cardiac technologist in 18 hospitals in seven states, moving from job to job -- despite being fired twice over allegations of drug use and theft.
Thirty-two people in New Hampshire have been diagnosed with the same strain of hepatitis C that Kwiatkowski carries, along with six in Kansas, five in Maryland and one in Pennsylvania.