David Kwiatkowski, a former medical technician at Exeter Hospital, is accused of stealing narcotics and spreading Hepatitis C to 32 patients in New Hampshire through contaminated syringes. He faces federal charges in connection with the outbreak.
Before he worked in New Hampshire, Kwiatkowski was temporarily employed at four hospitals in Maryland between 2008 and 2010, according to the review by Maryland's Department of Health and Mental Hygiene.
After the illnesses at Exeter Hospital and the alleged link to Kwiatkowski came to light, more than 1,700 patients in Maryland were tested for the chronic liver disease, and five patients to date have tested positive.
The Maryland review, released Wednesday, found that the outbreak there did not stem from any single gap or deficiency. Instead, it was the result of "multiple gaps in regulations, allied health professional credentialing and licensing procedures, and human resources and risk management practices at staffing agencies and facilities."
Among its findings:
--Interstate staffing agencies "are largely unregulated nationwide, creating risks for patients." It recommends expanding current regulations to include staffing agencies that place any healthcare workers.
--Kwiatkowski "falsely obtained and renewed his radiographer certification from the American Registry of Radiologic Technologists, and his license from the Maryland Board of Physicians." It recommends that board review and revise its licensing procedures.
--Co-workers and staffing agencies failed to report concerns about drug diversion to licensing boards and other employers during reference checks. It recommends possible legislation to provide "protective immunity" for such disclosures.
--An existing data bank for reporting medical misconduct should be expanded to include any health professionals "who may pose risk to patient safety, especially those who work in multiple states."
--Medical facilities should develop mandatory, standardized processes "to prevent and respond to drug diversion, including identifying and referring individuals at risk for treatment."
The New Hampshire Legislature is considering several measures stemming from the Exeter Hospital outbreak, including licensing medical technicians and drug testing healthcare workers.