Questions raised by dedicated caregivers at our community-based hospital have resulted in investigations that are rippling across the nation. A significant concern has surfaced: Is the American health care 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 risk assessment team notified the New Hampshire Department of Public Health. A possible connection was established to David Kwiatkowski, a radiology technician at the hospital. We removed him from his position. Following weeks of investigation by law enforcement and regulatory agencies, federal officials filed criminal charges against Mr. Kwiatkowski, alleging that while working as a technician in our Cardiac Catheterization Unit, he diverted patient medications for his own use. Worse, investigators believe he did this while knowingly carrying the hepatitis C virus, and that he infected more than 30 patients.

Incredibly, investigators probing Mr. Kwiatkowski’s past are discovering red flags that were not present in his employment or personal record. When Exeter Hospital hired Mr. Kwiatkowski, we reviewed a national criminal background check, a sanctions check in a federal health care database, and the results of a drug screening. In addition, two previous hospital employers gave him outstanding reviews, one calling him “invaluable.” Yet, federal investigators have now discovered that Mr. Kwiatkowski had allegedly been caught in another hospital diverting the powerful medication Fentanyl. He was fired, but no charges were filed and he was not convicted of a crime, so no record of this event was available to us. Two years later, an Arizona hospital 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 did not revoke his registration credential. In recent media reports an ARRT spokesman explained the group “did not have first-hand evidence against him.” In addition there is no federal databank that is designed to capture and make available to employers data concerning alleged criminal activity by an unlicensed health care worker.

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 that our staff identified that cluster. We stopped Mr. Kwiatkowski from working. We immediately notified authorities and have been assisting investigators ever since. But, as 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. health care system needs to do some soul-searching about an employee whose alleged behavior in my view, verges on domestic terrorism.

What needs to happen:

-- When references are sought, there should be mandatory disclosure by health care providers of problems with former employees that could pose a risk to patient safety. It should no longer be an option to say nothing or cover-up.

-- There needs to be a registry system covering all states and ALL workers involved in providing patient care, including information relevant to patient safety.

-- Legislators should protect hospitals that share this information from the threat of employment lawsuits.

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

Following a similar outbreak, the state of Colorado took several steps in this direction. We should look to build on that effort, seek out best practices elsewhere, and consider ideas surfacing here in New Hampshire. This is a time to act decisively, not to create 50 separate initiatives. However, it will require a collaborative effort by legislators and health care leaders 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 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 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 is president, CEO of Exeter Hospital