Cancer patients contract blood infection after a nurse tampered with their opioids

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Six cancer patients contract rare blood infection after a nurse, 27, stole liquid opioids and refilled the vials with contaminated tap water

  • Kelsey A Mulvey, 27, was charged in June with fraud and tampering, and faces up to 10 years in prison and a fine of $250,000
  • Six patients at Roswell Park Comprehensive Cancer Center in Buffalo, New York contracted a blood infection last summer
  • They were diagnosed with Sphingomonas paucimobilis – typically contracted from soil or dirty water
  • An inspection concluded that a nurse had been opening vials, taking some opioids out, and refilling the vials with tap water 

At least six cancer patients in New York contracted a rare blood infection from injectable opioids after a nurse allegedly opened the sealed syringes to steal some and filled them back up with tap water – muddying the vials in the process.

Kelsey A Mulvey, 27, was charged in June with fraud and tampering, and faces up to 10 years in prison and a fine of $250,000 for the alleged crime at Roswell Park Comprehensive Cancer Center in Buffalo, New York last year.  

This week, Roswell disclosed full details of their investigation into the case, in a report for the New England Journal of Medicine.

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According to the report, three of the six patients who contracted Sphingomonas paucimobilis – typically contracted from soil or dirty water – were diagnosed within days of one another, alerting doctors that something was afoot. 

At first, doctors suspected the drugs were contaminated, and checked the US Food and Drug Administration’s list of recalled medicines, but there was nothing. 

Finally, after analyzing the vials that were kept in a locked draw and interviewing staff, they concluded that Mulvey was stealing some of the opioids herself. 

Six patients at Roswell Park Comprehensive Cancer Center in Buffalo, New York contracted a blood infection last summer (file image)

Six patients at Roswell Park Comprehensive Cancer Center in Buffalo, New York contracted a blood infection last summer (file image)

According to the authors of the report, all doctors at Roswell, the alleged scam was extremely sophisticated – but for the contamination. 

There was barely any sign of tampering. 

‘A medication dispensing report showed that a nurse had repetitively and inappropriately accessed the locked drawer for narcotics storage,’ the authors wrote. 

‘Four of seven hydromorphone syringes that had been stored in the Pyxis medication-dispensing system grew S. paucimobilis and other waterborne bacteria.’ 

It was only through chemically analyzing the contents of the vials that they found some of them had been diluted.  

Then, it began to unravel. 

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The syringes were kept in drawers that could only be opened when a patient needed an infusion, but they found someone had been keying in patient data, opening the drawers, then canceling the transactions.  

Mulvey is accused of doing this on floors she was not assigned to, on her days off, and on three of her scheduled vacation days. 

What’s more, she is accused of failing to administer medication to 81 patients.   

All of the six patients recovered with antibiotics. Three later died, of factors unrelated to the infection, the authors said. 

The center put in place new surveillance cameras.

Mulvey was put on leave on June 28, 2018, resigning in July. 

‘Once again, this case illustrates the destructive power of opioid addiction,’ noted U.S. Attorney James P Kennedy Jr said. 

‘In this case, however, the harm caused by defendant’s actions resulted not only in harm to herself but in harm to some of the most compromised and vulnerable individuals in our community—those members of our community receiving cancer treatments. If we fail to take action to protect the most vulnerable among us, then we fail as a government.’ 



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