Nurse Injected Patients With Contaminated Tap Water

In a terrifying report published in the New England Journal of Medicine this week, public health officials identified a cluster of cases of Sphingomonas paucimobilis bacteremia. The cases all occurred in patients who received treatment at the same hospital. Upon further investigation, officials discovered that a nurse at the hospital had been diluting opioids with water in an attempt to divert the medication for her own use.

The infected individuals were all cancer patients receiving treatment at Roswell Park Comprehensive Cancer Center in Buffalo, New York. S. paucimobilis is a Gram-negative bacillus, which exists naturally in soil and water, but it rarely causes bloodstream infections, even in populations with weakened immune systems (such as cancer patients undergoing treatment like chemotherapy). The rarity of the bloodstream infections prompted an investigation by state officials. 

The investigation found syringes of hydromorphone that tested positive for S. paucimobilis and other waterborne bacteria. The syringes were stored in a locked drawer as part of the hospital’s automated medication dispensing system. Officials found records demonstrated that a nurse had “repetitively and inappropriately” accessed this drawer. Officials believe that the nurse was diluting the syringes with tap water in order to divert the opioids for personal use.

The report declined to name the nurse involved. However, earlier this summer, New York prosecutors announced criminal charges against Kelsey A. Mulvey, a former nurse at Roswell Park Comprehensive Cancer Center. They claimed that she used her position to steal pills and vials of medication, including Dilaudid, methadone, and oxycodone over a five-month period ending in June 2018. Her actions resulted in at least 81 patients not receiving their proper medication, according to the criminal complaint. Prosecutors stated that the former nurse was addicted to opioids and was using the stolen medication for personal use.

No deaths resulted from the infections, but some patients later died from unrelated causes, including complications of cancer. Upon discovery of the theft, Roswell Park has taken additional measures to prevent drug diversion, including enhancing security surveillance with video monitoring, reviewing current hospital policies, and increasing staff training and education.

Drug diversion occurs when a legal supply of prescription drugs is interrupted, and these drugs are transferred from a licit to an illicit channel. Diversion can result in the distribution of the drug, or, as in this New York case, personal use. Along with the increase in opioid addiction and overdose in the United States, rates of opioid diversion have also risen. According to the CDC and DEA, rates of opiate diversion increased exponentially from 2001 through 2010, plateaued from 2011 through 2013 but spiked again from 2013 to 2014.