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A year after David Kwiatkowski’s arrest, what New Hampshire learned about drug diversion in hospitals

A year ago last week, David Kwiatkowski was arrested in a Massachusetts hospital and charged with stealing anesthetic drugs at Exeter Hospital, where he worked and injecting himself, contaminating syringes that were later used on patients.

Since then, 47 people in four states – including 32 people in New Hampshire – have been diagnosed with the same strain of hepatitis C that Kwiatkowski carries and is accused of spreading during his time working in Exeter and other hospitals as a traveling technician.

Authorities said Kwiatkowski was not authorized to handle medication at Exeter Hospital, but they believe he may have found opportunities when authorized personnel weren’t watching to take syringes filled with the painkiller fentanyl and replace them with syringes he had used and refilled with another liquid, possibly saline.

Kwiatkowski has pleaded not guilty in federal court to 14 counts of stealing and tampering with controlled drugs and is set to go to trial in January.

Last month, the Division of Public Health published a report looking at the outbreak of the hepatitis C virus (HCV) at Exeter Hospital. I talked with division Director Jose Montero about what the state learned in its investigation.

What led to this situation? Are there policies or procedures that should have been in place in these hospitals that weren’t?

Policies and procedures only become real if each one of us exercises them 100 percent of the time. . . . We can write rules and regulations that are so strict they are impossible to enforce. This should not be about knee-jerk reactions to increase regulations, but how do we enforce the regulations we have. How do each one of us make sure these policies and procedures are followed? . . . We need to communicate with people that it doesn’t matter if you are working with a friend, we cannot assume everyone is going to do what they are supposed to do.

“Each one of the workers needs to realize they need to follow procedures even though it may sound redundant. They need to have their eyes on the medication and on their
co-workers. It’s not an issue of mistrust but of helping each other and helping the system. Does that make an atmosphere that is more adversarial and make it more difficult to collaborate? Maybe. That’s always the risk.

So this is an issue that’s larger than just Exeter Hospital?

There were systemic issues at play here. This health care worker who is alleged to have spread this disease worked in other states, and he was not stopped before now. That clearly shows that we are not properly dealing as a nation with issues around licensing and certifications. The federalism system we have is great for each state to choose its own way of doing this, but we should have some better national coordination.

This also raised the issue of “what do we do when we identify people with a drug addiction diagnosis.” We cannot forget that that is a clinical situation: They need treatment. But how do we manage that in a clinical setting, when there are so many opportunities for them to do the wrong thing, as it seems, based on our investigation was the case here?

Have you or anyone in the other states affected by this come up with recommendations on how to improve coordination across state lines on licensing and certifications of health care workers?

“We discussed with other states and with the CDC, but we don’t have a specific answer. It may require federal legislation; it may require a whole different set of rules. And in order to get to that, somebody needs to sit down and contact Congress. The Maryland health department wrote a report (Kwiaktowski is accused of infecting seven people in Baltimore) and they have a bigger agency so they did write something to that end, but to the best of my knowledge there is nothing happening at the federal level.”

(Sarah Palermo can be reached at 369-3322 or or on Twitter @SPalermoNews.)

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