Swapped Syringe Case Leads to Facility and Legislative Changes

The saga may be over as far as the courts are concerned, but the pain will last for the victims, and lessons will keep being learned by healthcare professionals. The saga? The debacle in which scrub technician Kristen Parker infected 18 people with her hepatitis C as a result of switching her own dirty syringes (which she would then fill with water or saline solution) with syringes of the pain-killer Fentanyl.

Parker, 27, was in late February sentenced to 30 years in jail. She worked at Rose Medical Center, in Denver, and Audubon Ambulatory Surgery Center, in Colorado Springs. According to The Denver Post, U.S. District Judge Robert Blackburn made Parker’s sentence even longer than what sentencing guidelines call for, which is 20 to 25 years.

Parker pleaded guilty to counts of tampering with a consumer product and five counts of obtaining a controlled substance by deceit or subterfuge, according to The News Press, a newspaper serving communities around the Denver area. The News Press reports that U.S. attorney David Gaouette said the sentence should bring victims some measure of resolution, was appropriate and reflects the seriousness of Parker’s conduct. “Today’s sentence should truly send a message that there are very serious consequences for these types of actions,” The News Press quoted Gauuette as remarking.

Leaders from the medical facilities at which Parker worked have said that policies have changed to make processes safer (fingerprint access, passcode-protected medications, etc.). Some lawmakers, however, want greater assurance. In late February, Colorado lawmakers announced new legislation that would require hospitals to red-flag employee names on incident reports that go to the state health department, according to Denver ABC affiliate 7 News. “Under the proposed bill, employers would also be required to check the database of names before hiring a surgical tech, and must report disciplining and firing of a surgical tech for issues that may be a violation of the Surgical Tech Practice Act,” 7 News reports.

Healthcare stakeholders nationwide should be scrutinizing the Parker case whether the law requires them to make changes or not. Can a scrub tech, or anyone else for that matter, get away with this criminal behavior at your facility? Rudolph Gonzales, RN, MSN, CNOR, CRCST, CHL, has been the manager of central sterile processing at Medical Center of Louisiana, of New Orleans, since 1991, and shares his advice.

Gonzales oversees the sterilization and disinfection services for the entire hospital, including clinics, the surgical department, labor and delivery, central supply and materials, the emergency department, respiratory and pulmonary departments and diagnostics and treatments department, which includes the GI lab. Gonzales also serves on an infection-control committee, an OR committee, and the LSU State Infection Control and Product Standardization Committee. Gonzales has 18 years of experience in the operating room and central sterile processing. He is the president-elect of the New Orleans Chapter of the Association of periOperative Registered Nurses (AORN), and is a member of the Association for the Advancement of Medical Instrumentation (AAMI) and the International Association of Healthcare Central Service Materiel Management (IAHCSMM).

ICT: Should every person be accountable for sharps safety, regardless of what department they work in, and regardless of whether they work with sharps directly?

Gonzales: All users—surgical technicians, surgeons, registered nurses that are scrubbed in, physicians and nurses on patient floors that do procedures and central service workers—are responsible for the use and proper disposal of sharps. As a perioperative nurse manager, I know that we are not fully aware of the disease processes that afflict the patients we care for. Therefore, we must treat all patients the same and should protect our fellow workers by using sharps as they are meant to be used and to dispose of those sharps in suitable sharps containers. Our policy is that all sharps are removed from knife handles and disposed of in the OR before those instrument sets are returned to central sterile processing. When a fall-out occurs, the personnel involved are counseled and if needed, reprimanded. AORN recommended practices address the methods to reduce sharps injuries and individual responsibilities to reduce such risks.

Infection prevention, the operating room and central sterile processing are the first line in preventing sharps mishaps. Working with our central supply department, we can review orders of sharps and knives that may go to other departments that should not have access to them. On-the-spot corrections are effective in reducing the amounts of sticks, but you need personnel making those corrections to have the full support of their chain of command. Personnel who become indignant because they are corrected may feel that they are above such corrections and may not heed a little friendly advice. Immediate feedback to the floor that sends instrument sets back with sharps on instruments also helps us to police such situations with the goal of retraining the person that left sharps on those sets.

ICT: What types of policies/tips can help healthcare teams ensure that their drug and needle supplies are being used appropriately, and how can they measure the efficacy of their systems? If tampering appears to have occurred, what should be done?

Gonzales: Honest, direct communication with leadership/management to immediately resolve such incidents and empowerment of staff to make the corrections in a professional manner would be the best ways to make for a strong program. Policies that include AORN-recommended practices, training, collaboration with surgeons and other healthcare professionals are essential in keeping sharps injuries to a minimum.

As far as tampering with medications that come prepackaged with sharps and personnel having access to syringes such that medications are being tampered with, the leadership/management should be vigilant and ensure/enforce that policies and procedures are followed.

An environment of open communication can help to identify when a person has a problem and may be gaining access to controlled substances. In those cases, the leadership and those who are empowered in the department should address this with the person that may be misusing their position to seek drugs for self use. Even our most-trusted fellow workers may fall into the trap of drug abuse and may not be able to seek help. If one is suspected, the question must be answered. Periodic auditing of drug stores and testing of personnel may be needed if missing drugs becomes evident. One indicator may be missing needles and syringes. Though we ask much of our leaders, this is just another facet of taking care of our workers and our patients.