What Happened
David M. Kwiatkowski, a traveling radiologic and cardiac catheterization technologist, stole fentanyl syringes intended for patients across hospitals in at least eight states, most recently Exeter Hospital in New Hampshire.
Kwiatkowski injected himself with fentanyl meant for patients undergoing medical procedures and replaced the drug with saline-filled syringes reused from earlier procedures. Knowing since at least June 2010 that he was infected with hepatitis C, he continued the practice, contaminating the replacement syringes with his infected blood. The scheme was uncovered after a hepatitis C cluster was detected among patients at Exeter Hospital in May 2012, triggering a multistate public-health investigation; the CDC recommended testing for more than 12,000 patients across the hospitals where he had worked, and dozens were confirmed infected, with at least one death linked to the outbreak.
Kwiatkowski pleaded guilty to eight federal counts of obtaining controlled substances by fraud and tampering with a consumer product. On December 2, 2013, he was sentenced to 39 years in federal prison.
What Went Wrong
A traveling technologist with a documented history of workplace drug problems moved between hospitals in multiple states before the pattern was connected to a public-health outbreak. Key failures included:
- Staffing agencies and hospitals did not share or check a traveling technologist's prior workplace drug-related terminations across facilities and states.
- Used syringes reused from earlier procedures were not verified before being filled and returned to circulation.
- The connection between a bloodborne-pathogen cluster and a single traveling employee's movement across hospitals took years to surface.
How It Could Have Been Prevented
- Verify a traveling or per-diem clinical worker's employment and disciplinary history across all prior facilities, not just the most recent employer.
- Prohibit reuse of any syringe, including for saline or flush purposes, once it has been used in a procedure.
- Investigate infection clusters with an unclear common source for a potential staff-level cause, especially where staff work across multiple facilities.
- Share verified diversion-related terminations across a staffing agency's network of client facilities.
Related Guidance
- Employee Screening & Fitness for Duty — DEA screening requirements (21 C.F.R. §1301.90) for staff with controlled substance access, including traveling and per-diem staff.
- Hospital Diversion Prevention Checklist — Hospital self-assessment covering procedural medication controls.
- 15 Red Flags of Drug Diversion — Behavioral and transactional indicators of diversion by clinical staff.