State report outlines Kwiatkowski's time in Maryland

Hospital worker accused of exposing thousands to hepatitis C

March 20, 2013|By Andrea K. Walker, The Baltimore Sun

Supervisors at a Maryland hospital weren't surprised when drugs were missing from a treatment room where contract radiology technician David Kwiatkowski was assigned.

A manager had spotted him going through needle-disposal containers and he was among three employees under suspicion for taking vials of the narcotic fentanyl from the cardiac catheter lab, a state investigation found.

But when a staffing agency later contacted the hospital about Kwiatkowski, a manager gave him a satisfactory review, writing: "David is very professional and worked very hard."

The incident at the Maryland facility, detailed in a state report released Wednesday, was just one example of what health officials called a systemwide breakdown that allowed Kwiatkowski to inject himself with stolen narcotics-filled syringes.

The technician, who was infected with hepatitis C, has been accused of leaving behind the contaminated needles, filled with saline, to be used on other patients at hospitals in several states. He exposed thousands of people to the life-threatening virus, including 1,700 in Maryland. Five patients in Maryland contracted the disease.

In December, Kwiatkowski pleaded not guilty to federal charges that included tampering with a consumer product and obtaining controlled substances by fraud. His trial is scheduled for October.

"I think that there were missed opportunities that could have stopped Mr. Kwiatkowski from diverting drugs in Maryland," said Dr. Lucy Wilson, chief of the state health department's epidemiology center, who helped investigate Kwiatkowski's actions during the time he worked at four Maryland hospitals from 2008 to 2010.

The report by the Maryland Department of Health and Mental Hygiene for the first time details Kwiatkowski's time working in the state.

For years, Kwiatkowski continued working at hospitals, despite being investigated by other facilities for allegedly stealing and using drugs. Kwiatkowksi often quit the jobs before investigations were completed, and the hospitals and staffing agencies often didn't pass on information to his new employers, according to the report.

The state investigation found gaps in the health care system, including problems in the way that staffing agencies screen applicants and a culture at hospitals that makes staff wary of reporting bad employees.

Government regulators also failed, not sufficiently verifying worker backgrounds and relying on applicants to self-report criminal history. Kwiatkowski failed to disclose a DWI arrest and other disciplinary actions that might have raised warning signs, the state report found. A national registry meant to flag problem workers did not list all of Kwiatkowski's transgressions.

"We found there wasn't one single overarching issue, but really it was instead multiple systemwide vulnerabilities in multiple arenas," Wilson said.

Kwiatkowski first started working in Maryland at the Baltimore VA Medical Center in June 2008, a job he got through Advance Med.

He first applied for a radiographer license with the Maryland Board of Physicians on Sept. 25, 2008, but failed to disclose suspensions and other terminations, the state report said.

He told the board about a 2001 DUI arrest, but not a 2005 DWI in Michigan, where he was sentenced to six months of probation. He didn't divulge that he quit a job at the University of Michigan Hospital after it suspended him in December 2006 because officials suspected he was stealing drugs, the report found.

In May 2008, a staffing company owned by Maxim Healthcare Services terminated Kwiatkowski's contract with the University of Pittsburgh Medical Center after he was caught with fentanyl syringes in his scrub pants and tested positive for narcotics. However, Columbia-based Maxim continued to place Kwiatkowksi in jobs in Maryland, and the technician failed to tell Maryland officials about that incident, the report said.

Analysts with the Board of Physicians only contact past employers that applicants list, so they did not know to call the Michigan or Pittsburgh hospitals, the state report said. The board doesn't do background checks, so it would not have caught any criminal history. Kwiatkowski was awarded a license that October.

Maxim assigned Kwiatkowski to Southern Maryland Hospital in Clinton on Nov. 9, 2008, to work in its cardiac catheterization lab. He was fired in February 2009 for falsifying time records and forging his supervisor's name on time sheets.

When Kwiatkowski filed to renew his Maryland application in June, he again failed to list suspensions and terminations, including the Southern Maryland Hospital incident, according to the state report. Maryland issued him a new license.

Kwiatkowski continued to work in Maryland for several more weeks, first at Johns Hopkins Hospital and then at Maryland General Hospital. He quit Maryland General unexpectedly in March 2010 and was classified by the hospital as not rehirable, ending his stint in the state, the report said.

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