July 09, 2017
2 min read

Nurse stealing opioids from patients’ syringes responsible for hospital outbreak

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A hospital nurse who tampered with opioid-containing syringes to syphon off the drug caused a 2014 outbreak of Serratia marcescens at the University of Wisconsin Hospital, resulting in five illnesses and one death, according to study findings publishing in Infection Control and Hospital Epidemiology.

“This incident sadly adds to the handful of health care-associated bacterial outbreaks related to drug diversion by a health care professional,” Nasia Safdar, MD, PhD, hospital epidemiologist at the University Hospital in Madison, Wisconsin, said in a press release. “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 health care-associated outbreaks related to gram-negative bacteria.”

Hospital staff identified six patients infected with S. marcescens within a 5-week period from March 1 to April 8, 2014. Because less than 10 S. marcescens bloodstream infections are usually identified in the facility each year, an outbreak investigation was subsequently launched. Through molecular typing, investigators determined that five of the six patients had identical S. marcescens isolates. Four of the patients affected by the outbreak recovered; however, one died from Serratia sepsis infection.

Shortly after the outbreak was detected, hospital staff discovered four hydromorphone and six morphine patient-controlled analgesia (PCA) syringes in an automated medication dispensing cabinet that had been tampered with. Toxicology lab testing revealed that seven of these syringes had undetectable levels of medication, which triggered a controlled substance diversion investigation. Almost a month later, three more hydromorphone PCA syringes appeared to have been tampered with and had undetectable levels of medication. After hospital staff identified another contaminated syringe while testing a random sample collected from the pharmacy and cabinets of different patient units, they removed and restocked all morphine and hydromorphone PCA syringes. Overall, staff found 42 syringes with evidence of drug diversion. The syringes appeared to have been filled with a saline or lactate-ringers-like solution instead of the active medication. A nurse working in the post-anesthesia care unit (PACU) was eventually linked to the diversion and immediately terminated.

Investigators then set out to determine whether the outbreak and diversion were possibly connected. They found that four of the patients were exposed to S. marcescens during a postoperative stay in the PACU. In addition, they discovered that the nurse accessed cabinets containing contaminated PCA syringes within a short period before the syringes were administered to all four patients. The only patient who did not visit the PACU was identified as the suspected nurse’s father, who lived with her before and after his hospitalization and was exposed to S. marcescens before his admission.


Safdar and colleagues hypothesized that the syringes became contaminated when the nurse withdrew the opioid medication and refilled them with saline-like solution. Because IV fluids from the PACU and inpatient pharmacy area did not have evidence of S. marcescens contamination, the researchers suggested that the replacement solution was brought in from a source outside of the hospital. No additional cases of S. marcescens were detected after the nurse was terminated.

“Unfortunately, in the context of the current U.S. epidemic of opioid addiction, our experience is not isolated,” they researchers wrote. “The CDC has reported a total of nine health care-associated bacterial and hepatitis C outbreaks related to drug diversion by health care workers within the last 30 years. The common mechanisms of infection were tampering with injectable controlled substances, such as opioids administered by PCA pumps, fentanyl syringes and vials.” – by Stephanie Viguers

Disclosure: The researchers report no relevant financial disclosures.