A nurse at a cancer clinic who tampered with opioid syringes has allegedly caused six patients to develop the same rare blood infection, according to a report. The report, published in the New England Journal of Medicine, does not identify the nurse but noted that he or she “had repetitively and inappropriately accessed the locked drawer for narcotics storage.”
The cluster of Sphingomonas paucimobilis bacteremia at Roswell Park Comprehensive Cancer Center in Buffalo, N.Y., affected six patients, whose ages ranged from 28 to 70 years old; the first three diagnoses were made within one week of each other. Medical staff were surprised because the infection is rare, even in patients with weakened immune systems, the report noted.
The center found no new sphingomonas infections at any regional microbiology labs, no Food and Drug Administration recalls, and no cases of contamination from their pharmaceutical vendors. When none of these outside factors panned out, they began looking inside—and discovered S. paucimobilis in “patient-controlled analgesia syringes of compounded hydromorphone,” according to the New England Journal of Medicine report.
One nurse in particular was found accessing a locked narcotics storage drawer several times. There were no “overt signs of tampering,” but several syringes tested positive for S. paucimobilis as well as other waterborne bacteria.
“We concluded that a portion of the narcotic had been removed and replaced with an equal volume of tap water, which contaminated the infusate with waterborne bacteria. There have been no additional waterborne bloodstream infections associated with drug diversion,” according to the report.
- paucimobilis is a rare, waterborne agent that can be found in water, soil, and plants. It is more likely to cause infections in a patient with a compromised immune system but could infect healthy patients, too. It has been linked to consequences including sepsis, septic pulmonary embolism, septic arthritis, peritonitis, and endophthalmitis, according to a 2017 report in the Journal of Korean Neurosurgical Society.
Although the New England Journal of Medicine did not reveal the identity of the nurse, several media outlets—including The Washington Post and Fox News—have identified the culprit as 27-year-old Kelsey Mulvey. According to a press release from the Western District of New York’s attorney’s office, Mulvey received charges including illegally obtaining controlled substances through fraud, tampering, and violating the Health Insurance Portability and Accountability Act. She faces up to 10 years in prison and a fine of up to $250,000.
According to the statement, Mulvey allegedly “fail[ed] to properly administer medication for 81 patients” between February 2018 and June 2018. She was placed on administrative leave on June 28, 2018, and resigned about two weeks later.
U.S. Attorney James P. Kennedy, Jr. said that the case highlights the impact of the opioid crisis.
“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,” Kennedy said in a statement. “If we fail to take action to protect the most vulnerable among us, then we fail as a government.”