Questions raised by dedicated physicians and caregivers at our 100-bed community-based hospital in southern New Hampshire have resulted in investigations that are now rippling across the nation. And one significant question has surfaced: Is the American healthcare system failing to share critical information about problem employees, resulting in a threat to patient safety?

In mid-May physicians affiliated with Exeter Hospital identified a small, but unusual cluster of hepatitis C cases among patients. Our internal risk assessment team followed up immediately and notified the New Hampshire Department of Public Health.

In a very short time frame, possible links were established between the hepatitis C cases and David Kwiatkowski, a radiology technician at the hospital and subsequently, Mr. Kwiatkowski was removed from his position.

Following weeks of investigation by multiple federal and state law enforcement and regulatory agencies, federal officials filed criminal charges against Mr. Kwiatkowski, alleging that while working as a technician in our hospital's Cardiac Catheterization Unit, he diverted and tampered with patient medications for his own illegal use. Worse, investigators believe he did this while knowingly carrying the hepatitis C virus, and that he infected numerous patients. To date, more than 30 patients have been identified and we are continuing to test patients who may have had even a slight risk of coming into contact with Mr. Kwiatkowski during his employment here.

Incredibly, the professional criminal investigators probing Mr. Kwiatkowski's past work record are discovering red flags that were not present in his employment and personal history at the time of his hire. When Exeter Hospital hired Mr. Kwiatkowski his national criminal background check, a sanctions check in a federal database, and the results of a pre-employment drug screening were all void of any information that would have challenged his appropriateness for employment for which he was applying. In addition, two previous hospital employers had provided outstanding performance reviews, one calling him “invaluable.”

Yet, federal investigators have since discovered that in another hospital in 2008, Mr. Kwiatkowski was allegedly caught red handed diverting the powerful medication Fentanyl. He was fired, but since no charges were filed and he was not convicted of a crime no record of this event was available to us.

Two years later, an Arizona hospital reported it fired Mr. Kwiatkowski after he was found unresponsive in a locker room, with syringes and needles. In that case, the American Registry of Radiologic Technologists (ARRT) was notified, but the ARRT did not revoke Mr. Kwiatkowski's registration credential. In recent media reports an ARRT spokesman explained the group “did not have first-hand evidence against him.” From those reports it appears the investigation was not completed and no other reporting of this event was forwarded to federal databases so that it would be available to future employers.

Following these incidents, Mr. Kwiatkowski was placed by staffing agencies at unsuspecting hospitals in Pennsylvania, Kansas and Georgia before presenting himself, with a clean record and properly credentialed, on our doorstep in New Hampshire. He worked at our hospital for about a year before our physicians spotted the hepatitis C patient cluster that became his undoing.

I am proud of the way our staff has handled this tragic situation. We stopped Mr. Kwiatkowski from working. We immediately notified authorities and we have been assisting investigators ever since.

But, as at least a dozen hospitals in eight states where Mr. Kwiatkowski previously worked consider whether they need to test patients for hepatitis C, it is becoming clear the U.S. healthcare system needs to do some soul-searching about an employee whose alleged behavior in my view, verges on domestic terrorism.

What needs to happen?

There should be mandatory reference disclosure by healthcare providers of problems with former employees that could pose a risk to patient safety. Further, as in the case of physicians and nurses who have national registries that track incidents associated with their professional practice, there needs to be a registry system covering all states that can track any healthcare worker who has direct patient care responsibilities and who has evidenced practices that present a risk to patient safety. It should no longer be an option to say nothing or cover up problems and legislators should find a way to protect hospitals that proactively share this information from the threat of employment related lawsuits.

I also agree with comments made recently by Dr. Joseph Perz of the Centers for Disease Control and Prevention in which he stated that hospitals nationwide should review what else can be done in terms of policies and practices to further restrict unauthorized access to medication.

Following a similar outbreak, the state of Colorado took several important legislative steps in this direction. We should look to build on that state's efforts, seek out best practices that may be in place in other states, and consider ideas surfacing here in New Hampshire. This is a time to act decisively in a coordinated fashion not to create 50 different unaligned initiatives. However, that will require a joint effort by legislators, care providers and clinical and policy experts, both here and across the country.

Mr. Kwiatkowski's arrest is a critical milestone in this incredibly difficult and painful situation.
My heart, and the hearts of the more than two thousand people with whom I work, goes out to the Exeter Hospital patients who have been affected, as well as their families, and to those patients who may have been impacted at other hospitals. It is critical to consider how to prevent tragic situations like this from ever happening again.

Kevin J. Callahan
President, CEO
Exeter Hospital