In 2006, nine patients at an Illinois hospital developed bloodstream infections with Achromobacter xylosoxidans. The Centers for Disease Control and Prevention lists the outbreak in its table of U.S. outbreaks associated with drug diversion by healthcare providers, and attributes it to a nurse at the hospital.
CDC notes that such outbreaks are investigated by CDC together with state and local health departments when healthcare providers tamper with injectable drugs. The agency describes these outbreaks as revealing gaps in the prevention, detection, or response to drug diversion in U.S. healthcare facilities.
The CDC source does not identify the drug diverted, how the diversion was detected, or any criminal, civil, or licensing outcome for the nurse. The agency advises facilities to maintain narcotics security measures and active monitoring systems to prevent and detect diversion.