5 infected after nurse tampered with syringes, diverted drugs in Wisconsin hospital

Five patients in different hospital wards within University Hospital in Madison, Wis., were infected with the same strain of bacteria after a nurse tampered with syringes to obtain opioids, according to a study in Infection Control & Hospital Epidemiology.

The five patients were infected with identical trains of Serratia marcescens, a gram-negative bacterium. One of them died from a Serratia sepsis infection.

Right after the S. marcescens outbreak was discovered, hospital staff found four hydromorphone and six morphine syringes that had been tampered with. This discovery led to a controlled substance diversion investigation.

The investigation found four of the five patients were infected after short stays in the post-anesthesia care unit where the nurse in question worked. The fifth patient was the nurse's father and had been infected prior to being admitted to the hospital.

The investigation also found the nurse had accessed the medication cabinets that housed the tampered syringes and likely replaced the narcotics with saline or another solution, which would then cause the infections. The nurse was immediately terminated.

"This incident sadly adds to the handful of healthcare-associated bacterial outbreaks related to drug diversion by a healthcare professional," said Nasia Safdar, MD, PhD, senior author of the study and a hospital epidemiologist. "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."

As a result of the incident, the hospital started using tamper-evident packaging and installed security cameras, among other changes.

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